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Rationale: Previous studies indicate active living environments (ALEs) are associated with higher physical activity levels across different geographic contexts, and could lead to reductions in hospital burden. Both Wales UK and Canada have advanced data infrastructure that allows record linkage between survey data and administrative health information. Objective To assess the relationship between ALEs and hospitalization in Wales and Canada. Methods We performed a population-based comparison using individual-level survey data from the Welsh Health Survey (N = 9968) linked to the Patient Episode Database for Wales, and the Canadian Community Health Survey (N = 40,335) linked to the Discharge Abstract Database. Using equivalent protocols and open-source data for street networks, destinations, and residential density, we derived 5-class measures of the ALE for Wales and Canada (classed 1 through 5, considered least favourable to most favourable for active living, respectively). We evaluated relationships of ALEs to health, behaviours and hospitalization using multivariate regression (reference group was the lowest ALE class 1, considered least favourable for active living). Results For Canada, those living in the highest ALE class 5 had lower odds of all-cause hospitalization (OR 0.66, 95% CI 0.54 to 0.81; as compared to the lowest ALE class 1). In contrast, those living in the highest ALE class 5 in Wales had higher odds of all-cause hospitalization (OR 1.37, 95% CI 1.04 to 1.80). The relationship between ALEs and cardiometabolic hospitalization was inconclusive for Canada (OR 0.75, 95% CI 0.50 to 1.12), but we observed higher odds of cardiometabolic hospitalization for respondents living in higher ALE classes for Wales (OR 1.46, 95% CI 1.10 to 1.78; comparing ALE class 4 to ALE class 1). Conclusion Canadian respondents living in high ALE neighbourhoods that are understood to be favourable for active living had lower odds of all-cause hospitalization, whereas Welsh respondents living in high ALEs that were deemed favourable for active living exhibited higher odds of all-cause hospitalization. Environments which promote physical activity in one geographic context may not do so in another. There remains a need to identify relevant context-specific factors that encourage active living.