Chronic care for all? The Intersecting Roles of Race and Immigration in Shaping Multimorbidity, Primary Care Coordination, and Unmet Healthcare Needs among Older Canadians

Objectives: Despite the predominance of chronic disease clustering, primary care delivery for multimorbid patients tends to be less effective and often uncoordinated. This study aims to quantify racial-nativity inequalities in multimorbidity prevalence (≥3 chronic conditions),access to primary care, and relations to past-year subjective unmet healthcare needs (SUN)among older Canadians. 
Methods: Population-based data were drawn from the Canadian Community Health Survey(2015-2018). Multivariable logistic regression was performed to estimate the likelihood of multimorbidity, sites of usual source of primary care (USOC), primary care coordination, and multidimensional aspects of SUN. The Classification and Regression Tree (CART) was applied to identify intersecting determinants of SUN. 
Results: The overall sample (n=19,020) were predominantly (69.4%) Canadian-born (CB)Whites (1% CB non-Whites, 18.1% White immigrants, and 11.5% racialized immigrants).Compared to CB Whites, racialized immigrants were more likely to have multimorbidity (Adjusted odds ratio [AOR]=1.35, 99%CI: 1.13-1.61), lack a USOC (AOR=1.41, 99% CI1.07 – 1.84), and report higher SUN (AOR=1.47, 99% CI: 1.02 – 2.11). Racialized immigrants’ greater SUN was driven by heightened affordability barriers (AOR=4.31, 99%CI: 2.02 – 9.16), acceptability barriers (AOR=3.11, 99%CI: 1.90 – 5.10) and unmet needs for chronic care (AOR=2.71, 99% CI: 1.53 – 4.80) than CB Whites. The CART analysis found that the racial-nativity gap in SUN perception was still evident even among those who had access to non-poorly coordinated care. 
Discussion: To achieve an equitable chronic care system, efforts need to tackle affordability barriers, improve service acceptability, minimize service fragmentation, and reallocate treatment resources to underserved older racialized immigrants in Canada.