Health Reports
Access to specialized health care services among older Canadians

Abstract

Background

Canada is experiencing rapid population aging, which has a wide range of implications, including an increased need for health care services. However, very few studies have examined use of specialized health care services (e.g., visits to medical specialists, non-emergency tests, and surgeries) among older Canadians.

Data and methods

Data from the Canadian Health Survey on Seniors – 2019/2020 were used to examine specialized health care service use among older Canadians. Latent class analysis was calibrated using a nationally representative sample of 39,047 Canadians aged 65 years or older to identify distinct patterns of need factors related to health care service use. Multivariable logistic regression, stratified by gender, was used to examine the association of predisposing characteristics, enabling resources, and need factors with specialized health care service use.

Results

In 2019/2020, an estimated 2.6 million older Canadians (43.4%) visited medical specialists, 1.4 million (23.2%) got non-emergency tests, and 0.6 million (10.4%) had non-emergency surgeries. Among those, 15.6% reported experiencing difficulties accessing services. Women were less likely than men to have visited medical specialists and have received non-emergency tests. Lower education was consistently associated with lower odds of specialized health care service use. Individuals in the multimorbidity, high stress–multimorbidity–disability,andpoor physical and mental health classes were more likely than those in the comparatively healthy class to use specialized health care services and to experience difficulties accessing them.

Interpretation

Findings of this study highlight gender differences and the importance of considering multidimensional need factors—ranging from physical health to mental health to psychosocial factors—in examining use of specialized health care services.

Keywords

health care use, medical specialists, non-emergency tests, non-emergency surgeries, older Canadians

Authors

Md Kamrul Islam and Heather Gilmour are with the Health Analysis Division at Statistics Canada.

 

What is already known on this subject?

• Sociodemographic characteristics and health status are associated with various types of health care service use, such as access to a regular medical doctor, hospitalization, and use of the emergency department.
• Women are less likely than men to use health care services, with some exceptions. However, less is known about gender differences in the influence of predisposing characteristics, enabling resources, and need factors in determining specialized health care service use among older Canadians.
• Canadians experience several difficulties accessing specialized health care services. Nonetheless, little is known about the extent to which older Canadians with distinct patterns of need factors experience difficulties in accessing specialized health care services.

What does this study add?

• An estimated 2.6 million older Canadians (43.4%) visited medical specialists, 1.4 million (23.2%) got non-emergency tests, and 0.6 million (10.4%) had non-emergency surgeries in 2019/2020. Older Canadians in the multimorbidity, high stress–multimorbidity–disability, and poor physical and mental health classes were more likely to use specialized health care services than those in the comparatively healthy class, even after controlling for predisposing and enabling factors.
• Having less than a postsecondary education was consistently associated with each type of specialized health care use for both men and women. The association between service use and factors such as age group, immigrant status, household income, having a regular doctor, rural residence, and being surveyed during the COVID-19 pandemic varied by type of specialized service and gender.
• Among older Canadians who accessed specialized health care services in 2019/2020, an estimated half million (15.6%) reported having difficulty in getting the services. Women in all need groups had higher odds of experiencing such difficulties than did women in the comparatively healthy group. For men, this was the case for those in the high stress–multimorbidity–disability and the poor physical and mental health classes.
• Common difficulties in accessing health care services included difficulty getting a referral, difficulty getting an appointment, the wait time being too long between the appointment and getting the services, and services not being available at the time required.

Introduction

Canada is experiencing rapid population aging. The aging of Canada’s population is mostly driven by aging baby boomers, increasing life expectancy, and decreasing fertility. In 2021, 18.5% of the population was aged 65 years or older, an increase from 13.0% in 2001.^Note 1 By 2030, this is projected to reach between 21.4% and 23.4% of the population.^Note 2 Older people are more likely to have multiple and complex health conditions and, in 2020, accounted for 44% of health expenditures in Canada.^Note 3 Thus, health care use, including specialist care use, would be expected to increase in the future.

A substantial body of literature has looked at the use of health care services among Canadians.^Note 4, ^Note 5, ^Note 6, ^Note 7, ^Note 8, ^Note 9, ^Note 10 Studies have examined access to a regular medical doctor,^Note 9, ^Note 11 hospitalization,^Note 10, ^Note 12 use of the emergency department,^Note 13 and medication use.^Note 14 However, only a few studies have investigated the use of health care services by older Canadians (65 years or older),^Note 4, ^Note 9, ^Note 10 with a focus on medical specialists, non-emergency tests, and non-emergency surgeries (hereafter, specialized health care services), and difficulty in accessing these services.^Note 15 Ensuring adequate access to specialized health care services, including non-emergency tests and surgeries, has many health benefits—particularly for high-risk populations such as older adults—including better detection and treatment of health problems and avoidance of further deterioration of existing health conditions.^Note 16, ^Note 17

Drawing on Andersen’s behavioural model of health service use,^Note 18 many predisposing and enabling factors, such as gender, age, marital status, immigrant status, rurality, education, employment, income, and having a regular doctor, have been identified as factors associated with various types of health care use.^Note 4, ^Note 5, ^Note 6, ^Note 8, ^Note 9, ^Note 10 Individual need factors such as health status and loneliness have also been associated with health service use.^Note 5, ^Note 6, ^Note 7 However, identifying patterns of need factors that frequently appear together recognizes the heterogeneity of health profiles and that individual need factors do not necessarily occur in isolation.^Note 19 To achieve this, latent class analysis (LCA) was used to classify respondents into unique multidimensional needs groups. 

Using data from the 2019/2020 Canadian Health Survey on Seniors (CHSS), this study examines the prevalence of specialized health care service use (medical specialist, non-emergency medical tests, non-emergency surgery) and evaluates the association of predisposing factors, enabling resources, and need-related factors with specialized health care service use in the past 12 months among Canadians aged 65 or older living in the community. Additionally, prevalence of and factors associated with experiencing difficulties accessing specialized health care services and the types of difficulties experienced were assessed. Men and women were analyzed separately.

The data for the 2019/2020 CHSS were collected both before COVID-19 pandemic restrictions (January to December 2019, and January to March 2020) and during the pandemic (September to December 2020). There are many factors that may have influenced health care use during the pandemic (e.g., cancellation of non-emergency procedures and reduced in-person visits).^Note 20, ^Note 23 Thus, the timing of the survey data collection was included in the analysis.

Methods

Data source

The CHSS 2019/2020, a cross-sectional supplement to the Canadian Community Health Survey (CCHS), collected information from 41,635 respondents aged 65 years or older living in the 10 provinces. The survey excludes people living on reserves and other Indigenous settlements in the provinces, full-time members of the Canadian Forces, the institutionalized population, and people living in certain health regions. Data were collected from January 2019 to December 2020, with a pause from April 2020 to August 2020 because of the pandemic. The response rate for the 2019/2020 CHSS was 40.1%; 90.8% of respondents agreed to link their answers to the CCHS. Detailed documentation for the 2019/2020 CHSS is available at https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5267.

Study sample

Proxy respondents (n=2,311) were not asked questions for the access to health care services module and were excluded. In addition to the question on sex at birth, respondents were asked, “What is your gender?” Responses were categorized as male, female, or gender diverse. Those classified as gender diverse (<10) and those who did not report their gender (<10), as well as those who did not report whether they required a visit a medical specialist (n=70), non-emergency surgery (n=48), or non-emergency tests (n=194) in the last 12 months of the survey, were also excluded. Thus, the final sample for the study included 39,047 individuals (16,600 men and 22,447 women), representing 5.9 million Canadians aged 65 or older living in the community. The demographic and socioeconomic distribution of the study sample is shown in Appendix A.

Outcome variables

Respondents were asked about their use of three types of specialized health care services, and whether they had any difficulties in getting these services. Four separate outcome variables were created based on whether an individual

1. required a visit to a medical specialist for a diagnosis or a consultation in the past 12 months (yes or no) (such as a cardiologist, endocrinologist, allergist, urologist or gynecologist, or psychiatrist [excluding an optometrist])
2. required non-emergency surgery in the past 12 months (yes or no); this includes surgery not provided in an emergency, such as cardiac surgery, joint surgery (knee or hip), and cataract surgery, excluding laser eye surgery 
3. required non-emergency tests (MRI, CT scan, angiography) in the past 12 months (yes or no) 
4. experienced difficulties in getting any of the specialized health care services in the past 12 months (yes or no).

Covariates

Drawing on Andersen’s behavioural model of health service use^Note 18, ^Note 24, ^Note 25 three types of covariates were selected: predisposing characteristics, enabling resources, and need factors. Predisposing characteristics are related to the tendency to use health care services. Enabling resources refers to the availability of services and personnel and the knowledge and ability to access them. Need-related factors, such as health status, influence the need for services.

Predisposing characteristics

Respondents’ gender, age, and marital status were included in the analysis as predisposing characteristics.^Note 26 Based on the question “What is your gender?”, two categories of gender(male and female) were used in the study. Age groups used were 65 to 74, 75 to 84, and 85 years or older. Marital statuswas classified as married or common-law; divorced, separated, or widowed; and single (never married). Immigrant statuswas categorized as European immigrant, non-European immigrant, and Canadian-born individual.

Enabling resources

The highest level of educationwas classified as less than postsecondary or postsecondary and above. The average household income of seniors’ households from 2019 to 2020 was used as the cut-off point,^Note 27 and total household incomewas categorized as less than $70,000 or $70,000 and above. Having a regular medical doctor was included as dichotomous (yes or no). Place of residence was coded as urban or rural.

Need factors

Previous studies have documented a wide range of factors influencing health care service use, such as physical health,^Note 5 mental health,^Note 28 and psychosocial factors.^Note 29 Drawing on previous studies, eight dichotomous items, including both physical and psychosocial health domains, were used as need factors in the analysis: perceived general health (poor or fair versus good, very good, or excellent); perceived life stress (extremely stressful, quite a bit stressful, a bit stressful, or not very stressful versus not at all stressful); self-reported diagnosis of mood disorder (yes or no) and anxiety disorder (yes or no); obesity (obese classes I, II, or III) versus not obese (overweight, normal weight, or underweight), derived based on self-reported height and weight; multimorbidity, i.e., two or more chronic conditions diagnosed by a health professional (asthma, chronic obstructive pulmonary disease, sleep apnea, fibromyalgia, arthritis, osteoporosis, high blood pressure, high blood cholesterol or lipids, heart disease, stroke, diabetes, cancer, Alzheimer’s disease, chronic fatigue syndrome, back problems, chronic kidney disease, bowel disorder, urinary incontinence, Parkinson’s disease, cataracts, glaucoma, diabetic retinopathy, or age-related macular degeneration); disability (none or mild versus moderate or severe) based on the Health Utilities Index Mark 3;^Note 30 and loneliness based on the Three-Item Loneliness Scale, with scores of at least 5 labelled as lonely.^Note 31, ^Note 32 In accordance with findings of previous studies, it was expected to find greater use of specialized health care service use among older Canadians with a higher concentration of need factors. The weighted percentage distribution of the need factors is shown in Appendix B.

Timing of the surveywas classified as before COVID-19 pandemic restrictions (January to December 2019, and January to March 2020) and during the COVID-19 pandemic (September to December 2020). This variable was included in bivariate analysis and as a covariate in multivariable analysis to assess whether the timing of survey data collection was related to the outcome variables.

Respondents were asked whether they had experienced any difficulties getting each type of specialized health care service in the past 12 months and what types of difficulties they experienced. Because of sample size limitations, factors associated with difficulties were analyzed for all specialized services together, rather than separately.  

Analytical approach

LCA was used to identify distinct groups based on eight need factors. The objective was for the individuals within groups to be similar to each other while distinct from those in other groups. LCA can identify the most common patterns of health need factors that frequently appear together and recognizes the heterogeneity of health needs among older Canadians. It also recognizes that individual factors do not necessarily occur in isolation and may have a synergistic effect on each other.

The optimal number of groups, in this case five, was determined by the Akaike information criterion, Bayesian information criterion (BIC), and sample-adjusted BIC, whereby lower values indicate better model fit.^Note 33 The entropy value of 0.90 in the five-class model indicates very good separation of classes (Table 1). The percentage of respondents in the smallest class was 5.7%, indicating an adequate number of respondents for calibrating regression analysis. The LCA was implemented in Stata 17.0, and individual sampling weights were used.



Each respondent was assigned to a class based on the highest probability of class membership. The five mutually exclusive classes were labelled as comparatively healthy, high stress, multimorbidity, high stress–multimorbidity–disability, and poor physical and mental health. The comparatively healthy class comprised 32.6% of the total sample, the high stress class 15.3%, the multimorbidity class 23.2%, the high stress–multimorbidity–disability class 23.2%, and the poor physical and mental health class 5.7%. Those in the comparatively healthy class had the lowest probabilities of need factors, while those in the poor physical and mental health class had the highest probabilities (Table 2).



Weighted percentages and cross-tabulations of specialized health care service use and difficulty in getting the services were estimated. Multivariable logistic regression was used to evaluate the association of predisposing factors, enabling resources, and need-related factors (represented by five LCA classes) with specialized health care service use and difficulty accessing services. Missing cases were very low, ranging from 0.1% (marital status) to 1.2% (education). Listwise deletion of missing cases was applied in calibrating the regression models.

Sampling weights were used to account for the survey design and non-response. Bootstrap weights were applied using SAS-callable SUDAAN 11.0.3 to account for the underestimation of standard errors caused by the complex survey design.^Note 34 The significance level was set at p < 0.05.

Results

Characteristics of the study population

The study population represents 3.2 million women and 2.7 million men aged 65 years or older (54.0% were women and 46.0% were men) living in private households in the 10 provinces. The majority were aged 65 to 74 years, married or living in common-law, and born in Canada. More than half of the study population had a postsecondary education or higher. Among men, 53.6% had a household income of $70,000 and above; 42.7% for women. Most had a regular medical doctor and were living in urban areas. The majority were in the comparatively healthy class (44.1% for men and 38.3% for women), and 3.2% of men and 6.6% of women were in the poor physical and mental health class (Appendix A).

Specialized health care service use

Based on the 2019/2020 CHSS, an estimated 2.6 million older Canadians (43.4%, 95% confidence interval [CI]: 42.5% to 44.4%) reported visiting medical specialists, 1.4 million (23.2%, 95% CI: 22.3% to 24.0%) reported getting non-emergency tests, and 0.6 million (10.4%, 95% CI: 9.9% to 11.1%) reported getting non-emergency surgeries in the past 12 months, with women being significantly less likely than men to have visited medical specialists or received non-emergency tests. Among men, those aged 75 to 84 years were more likely to visit medical specialists and get non-emergency tests than those aged 65 to 74 years. Among women, those aged 85 years or older were less likely to visit medical specialists and get non-emergency tests than those aged 65 to 74 years (Table 3).



Those with less than a postsecondary education were less likely to visit medical specialists and get non-emergency tests and surgeries. Similarly, having a household income of less than $70,000 was associated with a lower likelihood of visiting medical specialists and getting non-emergency surgeries (for men, but not for women). Those with a regular medical doctor were more likely to visit medical specialists and get non-emergency tests and surgeries (for women, but not for men).

Older Canadians in the multimorbidity and high stress–multimorbidity–disability classes were significantly more likely to use each type of specialized health care service than those in the comparatively healthy class—for both men and women. This was also true for those in the poor physical and mental health class, with one exception in the case of non-emergency surgery for men.

Multivariable findings

Overall, women had significantly lower odds than men of visiting medical specialists or getting non-emergency tests, even after accounting for predisposing characteristics, enabling resources, and need factors (not shown). There were no gender differences in getting non-emergency surgeries (not shown).

Some age differences remained significant in multivariable analysis for visiting medical specialists and getting non-emergency tests. Men aged 75 to 84 years had higher odds of using these services than those aged 65 to 74 years, while women aged 85 years or older had lower odds of doing so (Table 4).



In several instances, immigrants were less likely to have used specialized health care services than their Canadian counterparts (Table 4). For example, women who immigrated from non-European countries had lower odds of visiting medical specialists (0.7), men from European countries had lower odds of getting non-emergency tests (0.7), and men from both European and non-European countries had lower odds of getting non-emergency surgeries (0.6 and 0.5, respectively).

Consistently for both genders, those with less than a postsecondary education were less likely to have used each of the specialist health care services (odd ratios 0.6 to 0.8) than those with higher levels of education (Table 3). However, a household income of less than $70,000 was independently associated with lower odds of visiting medical specialists (0.8) and getting non-emergency surgeries (0.7) for men only.

Both men and women with a regular medical doctor had higher odds than those without a regular medical doctor of visiting medical specialists (1.9 for men and 1.8 for women) and of getting non-emergency tests (1.8 for men and 2.2 for women).

Men and women living in rural areas had lower odds than those in urban areas of visiting medical specialists, and women in rural areas had lower odds of getting non-emergency tests.

Strong associations were apparent with each of the specialized health care services for both men and women in the multimorbidity, high stress–multimorbidity–disability, and poor physical and mental health groups, compared with the comparatively healthy group. For example, for women, the increased odds of having visited a medical specialist were 1.9 in the multimorbidity group, 2.8 in the high stress–multimorbidity–disability group, and 3.8 in the poor physical and mental health group. In addition, women in the high stress class had 1.5 times higher odds of visiting medical specialists than women in the comparatively healthy class.

Regarding non-emergency tests, compared with the comparatively health class, odds ratios were 1.5 for men in the multimorbidity class, 2.6 for men in the high stress–multimorbidity–disability class, and 2.9 for men in the poor physical and mental health class. For women, the odds of getting non-emergency tests in the three classes were 1.6, 2.5, and 3.5, respectively.

In the case of non-emergency surgeries, odds ratios for men were 1.3 in the multimorbidity class, 1.5 in the high stress–multimorbidity–disability class, and 1.6 in the poor physical and mental health class, compared with the comparatively healthy class. For women, the odds of getting non-emergency tests in the three classes were 1.4, 1.8, and 2.1, respectively.

The associations between COVID-19 and using specialized medical services were significant in a couple of cases—men had lower odds (0.8) of visiting medical specialists during the pandemic than before pandemic-related restrictions, and women had lower odds of getting non-emergency tests during the pandemic. It is worth mentioning that these findings are representative of older Canadians at the aggregate level (combined for all provinces). Given that there were considerable differences in pandemic-related restrictions across provinces, use of specialized medical services among older Canadians may vary significantly across provinces.

Difficulty in accessing specialized health care services

Among older Canadians who accessed specialized health care services in 2019/2020, an estimated half million (15.6%, 95% CI: 14.6% to 16.6%) reported having difficulty getting these services. Women were more likely than men to experience difficulty visiting medical specialists and getting non-emergency tests (Chart 1). Although women were less likely than men to have visited medical specialists and gotten non-emergency tests, the factors independently associated with use of each type of specialist service were broadly similar for both men and women, with a few exceptions.

Description of Chart 1



Data table for chart 1
Table summary
This table displays the results of Data table for chart 1 Percent and 95% confidence interval, calculated using lower and upper units of measure (appearing as column headers).

	Percent	95% confidence interval
		lower	upper
Medical specialists
Men	11.5	10.2	12.9
Women	15.2Note *	13.7	16.7
Non-emergency tests
Men	7.5	6.2	8.9
Women	10.6Note *	9.0	12.4
Non-emergency surgery
Men	17.0	13.9	20.6
Women	19.0	16.5	21.9
Note * significantly different from men (p < 0.05) Return to note * referrer Source: The 2019/2020 Canadian Health Survey on Seniors.

Approximately one-half or more of older Canadians cited waiting too long as a difficulty in obtaining specialized health care services (e.g., too long between booking appointment and visit, too long to get appointment or surgery). Difficulty getting an appointment or referral was also commonly mentioned (Table 5).



Overall, women had significantly higher odds than men of experiencing difficulty in getting specialized health care services, even after adjusting for the predisposing characteristics, enabling resources, and need factors (not shown). 

Factors independently associated with lower odds of experiencing difficulty in getting specialized health care services included being 75 to 84 years of age for men (0.8) or 85 or older for women (0.5), being a non-European immigrant for women (0.6), having less than a postsecondary education for both men and women (0.7), and having a regular medical doctor for men (0.6) (Table 6).



Women who immigrated from European countries were 40.0% more likely to have had difficulty getting specialized medical services than Canadian-born women. Both men and women in the high stress–multimorbidity–disability, and poor physical and mental health classes were more likely to have had difficulties than those in the comparatively healthy class. For women, this was also the case for those in the high stress and multimorbidity classes.

Discussion

According to the 2019/2020 CHSS, an estimated 2.6 million older Canadians (45.4%) visited medical specialists, 1.4 million (23.2%) got non-emergency tests, and 0.6 million (10.4%) had non-emergency surgeries. Among those who accessed specialized health care services, 0.5 million (15.6%) reported difficulty in accessing them.

This study was particularly interested in examining gender differences in factors associated with use of specialized health care services. Although women were less likely than men to have visited medical specialists and gotten non-emergency tests, the factors independently associated with use of each type of specialist service were broadly similar for both men and women, with a few exceptions. With respect to gender, previous studies reported mixed findings on health service use. For example, women were more likely to use primary care services,^Note 35, ^Note 36 but less likely to use emergency and hospital services.^Note 35, ^Note 37 Similarly, women had a lower likelihood of using mental health services from specialists.^Note 38, ^Note 39 Previous studies have pointed to various factors for gender disparities in health services use, including differences in health perceptions and attitudes,^Note 35 morbidity patterns,^Note 35, ^Note 40 mental health status,^Note 40 social structural factors (e.g., socioeconomic conditions, social support, family arrangement),^Note 41, ^Note 42 and immigrant status and race or ethnicity.^Note 43, ^Note 44 In addition, the lower use of specialized health care service use among women may be attributable to their greater difficulties accessing these services, as shown in this study. Among other factors, the lower use of specialized health care services among women during the pandemic may be partly because of their greater fear of exposure to COVID-19 in a health care setting.^Note 20 

Consistent with expectations, higher odds of visiting medical specialists and getting non-emergency tests were noted with increasing age among men (for those aged 75 to 84 years compared with those aged 65 to 74 years). However, women aged 85 years or older had lower odds of visiting medical specialists and getting non-emergency tests, despite having lower odds of experiencing difficulties in accessing specialized health care services than did women aged 65 to 74 years. It may be that the CHSS target population (those living in the community) results in a healthy respondent bias. By excluding those who are living in institutions, and most likely to be in poor health, this study may underestimate the need for specialized health care services, particularly among women aged 85 years or older. In this age group, 31.5% of women and 19.5% of men were living in health care and related facilities in 2021.^Note 45, ^Note 46 

Some findings from this study indicate that immigrants were less likely to access specialized health care services, although there were differences by gender and type of service. Immigrants from non-European countries had lower odds than their Canadian-born counterparts of visiting a medical specialist (women), having non-emergency tests (men), and having non-emergency surgeries (men), while European immigrants had lower odds of having non-emergency surgeries (men). Although it is not possible to directly compare because of differences in the study population and factors considered in the analysis, previous studies have documented lower use of health care services among immigrants than the host country population^Note 44, ^Note 47 and attributed this to structural obstacles (e.g., difficulty in transportation or in obtaining permission to seek treatment during work hours) and cultural barriers (e.g., lack of linguistically and culturally appropriate health services). In this study, associations between immigrant status and difficulties getting services were mixed—no association for men, and among women, European immigrants had higher odds of having difficulties, while non-European immigrants had lower odds of having difficulties than Canadian-born women. Further research is needed using a relatively large sample to uncover potential reasons for the lower odds of having difficulties accessing specialized health care services among non-European immigrant women.

Lower socioeconomic status, particularly having less than a postsecondary education, was found to be associated with lower odds of visiting medical specialists and having non-emergency tests and surgeries. Men with lower income had lower odds of visiting a medical specialist and having non-emergency surgeries. Previous studies have also detected lower use of specialized health care services among those with lower socioeconomic status,^Note 9 even though they might have a higher need for these services because of poorer physical and mental health compared with their peers with higher socioeconomic status.^Note 48 Pulok and Hajizadeh^Note 9 detected that education was the most important contributor to inequity in specialist visits after income among older Canadians. While Canada’s universal health care system (Medicare) provides free access to hospital and physician services, barriers related to accessibility (e.g., ability to obtain referrals, travel cost) and affordability of health care services (e.g., lack of universal coverage for prescription drugs) may play a role in the lower use of specialized health care services among those with lower income.^Note 9

In 2021, 4.7 million Canadians aged 12 years or older (excluding the territories) (14.5%) did not have a regular health care provider. Of them, 0.4 million were aged 65 years or older.^Note 49 Having a regular doctor was associated with approximately twice the odds of visiting a medical specialist or getting non-emergency tests. This finding is in keeping with the structure of the health care system in Canada, where seeing a specialist requires a referral from a family doctor. Residents in rural areas were less likely to visit medical specialists or get non-emergency tests (women only), perhaps because of reduced access to primary care for referrals and the concentration of specialist services in urban areas.^Note 50 

Limited access to non-urgent health care and concerns about being exposed to COVID-19 in a health care setting^Note 20 might have been expected to result in lower odds of specialized health care service use during the pandemic. However, such lower odds were evident only for men in visiting medical specialists and for women in getting non-emergency tests. Increased use of virtual care options during the pandemic could have replaced some types of in-person specialized health care services, but these varied by province, and were less likely to be used by adults aged 65 or older.^Note 51

This study identified five distinct health need classes based on eight physical, mental, and psychosocial factors. Odds of specialized health care service use increased with higher concentrations of health conditions. For example, those in the poor physical and mental health class had higher odds of visiting medical specialists and getting non-emergency tests and non-emergency surgeries than those in the comparatively healthy class. It is worth repeating that the poor physical and mental healthclass is characterized by higher probabilities of having all of the eight need factors: fair or poor perceived general health, perceived life stress, mood disorder, anxiety disorder, obesity, multimorbidity, disability, and loneliness. In a broader sense, these results corroborate the findings from previous research,^Note 5, ^Note 6, ^Note 7, ^Note 10 which were based on individual need factors—not combinations of factors—such as multimorbidity, and poor physical and mental health.

Findings of this study identify the proportion of older adults with multidimensional need factors and add insight into the effects of combined need factors on specialized health care service use among older Canadians. Those living with mental health conditions in addition to poor physical health and psychosocial issues (e.g., loneliness) were more likely to use specialized health care services. Recognizing the complexity of the health needs of this group of older adults may help inform optimal specialized health care service delivery to Canadians.

Women and those with higher need factors (e.g., high stress–multimorbidity–disability and poor physical and mental health classes) were more likely to have experienced difficulty accessing specialized health care services. This is consistent with previous research.^Note 15, ^Note 20, ^Note 52 The most common difficulties experienced by older Canadians in 2019/2020 included difficulty getting a referral, difficulty getting an appointment, wait time being too long (for both getting an appointment and getting the service after appointment), and services not being available either at the time required or in the area. A recent study revealed that the waiting time from referral by a general practitioner to consultation with a specialist increased to 11.1 weeks in 2021 from 10.5 weeks in 2020. The study also found that Canadians experienced significant waiting times for various diagnostic technologies: for example, 5.2 weeks a CT scan, 10.2 weeks for an MRI, and 3.6 weeks for an ultrasound.^Note 53

Difficulties accessing specialist care could have consequences such as decreased compliance with treatment and delays seeking and obtaining treatment, resulting in exacerbation of existing conditions, suboptimal diagnosis, poor quality of life, or even mortality at the individual level and increased financial burden at the health care system level.^Note 15, ^Note 54 This is particularly important in the context of the aging population with a high prevalence of health conditions and increased demand for specialist services.

Strengths and limitations

To the best of the authors’ knowledge, this is the first analysis that identified patterns of need factors—applying LCA—and their association with specialized health care service use among older Canadians. The large sample size in the 2019/2020 CHSS facilitated separate analysis for men and women. This paper also evaluated the extent to which older Canadians experienced difficulties in accessing specialized services and types of difficulties experienced. 

However, this study has some limitations. The CHSS excludes information on on-reserve populations, as well as those in institutional settings such as long-term care and nursing homes, who may be more likely to need specialized health care services. Thus, findings are not necessarily representative of this population group. Finally, data collection for the 2020 CHSS was interrupted by the COVID-19 pandemic, and the inability to conduct in-person interviews during the pandemic resulted in lower response rates. Survey weights were used in the analyses to minimize any potential bias that could arise because of low response rates.

Conclusion

This national, population-based study of specialized health care use among older Canadians identified predisposing, enabling, and multidimensional need groups associated with specialized health care use among older Canadians. Women, immigrants, those with lower socioeconomic status, and those living in rural areas were less likely to use these services in some cases, while those with a regular medical doctor and worse health profiles were more likely to do so. A better understanding of the characteristics of older Canadians who use specialized health care services, by type of service and gender, can inform service delivery policies and programs and help to identify inequities. Findings of this study also highlight the importance of considering the heterogeneity of health need factors—ranging from physical health to mental health to psychosocial factors—in examining specialized health care service use and difficulty in getting those services.