title: Health Services Utilization, Specialist Care, and Time to Diagnosis with Inflammatory Bowel Disease in Immigrants to Ontario, Canada: A Population-Based Cohort Study.
abstract: Canada has amongst the highest incidence of inflammatory bowel disease (IBD) in the world, and the highest proportion of immigrants among G8 nations. We determined differences in prediagnosis delay, specialist care, health services use, and risk of surgery in immigrants with IBD.
  
  
  
  All incident cases of IBD in children (1994-2009) and adults (1999-2009) were identified from population-based health administrative data in Ontario, Canada. Linked immigration data identified those who arrived to Ontario after 1985. We compared time to diagnosis, postdiagnosis health services use (IBD specific and related), physician specialist care in immigrants and nonimmigrants, and risk of surgery between immigrants and nonimmigrants.
  
  
  
  Thousand two hundred two immigrants were compared with 22,990 nonimmigrants. Immigrants had similar time to diagnosis as nonimmigrants for Crohn's (hazard ratio [HR] 1.002; 95% confidence intervals [CIs] 0.89-1.12) and ulcerative colitis (HR 1.073; 95% CI 0.95-1.21). For outpatient visits, immigrants with IBD were seen by gastroenterologists more often than nonimmigrants. Immigrants had greater IBD-specific outpatient health services use after diagnosis (odds ratio 1.24; 95% CI 1.15-1.33), emergency department visits (odds ratio 1.57, 95% CI 1.30-1.91), and hospitalizations (odds ratio 1.19; 95% CI 1.02-1.40). In immigrants, there was lower risk of surgery for Crohn's (HR 0.66, 95% CI 0.43-0.99) and ulcerative colitis (HR 0.52, 95% CI 0.31-0.87).
  
  
  
  Immigrants to Canada had greater outpatient and specialty care and lower risk of surgery, with no delay in diagnosis, indicating appropriate use of the health system.
authors.affiliation: *Children's Hospital of Eastern Ontario IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; †Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; ‡School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada; §Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; ‖Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ¶Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; **Mount Sinai Centre for Inflammatory Bowel Disease, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; ††Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; and ‡‡Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Eric I
authors.initials: EI
authors.lastname: Benchimol
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Manuel
authors.forename: Nassim
authors.initials: N
authors.lastname: Mojaverian
authors.forename: David R
authors.initials: DR
authors.lastname: Mack
authors.forename: Geoffrey C
authors.initials: GC
authors.lastname: Nguyen
authors.forename: Teresa
authors.initials: T
authors.lastname: To
authors.forename: Astrid
authors.initials: A
authors.lastname: Guttmann
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D015331:Cohort Studies; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data*; D005260:Female; D005762:Gastroenterology / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D015212:Inflammatory Bowel Diseases / Q000175:diagnosis / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D013997:Time Factors