High Health Care Utilization and Costs Associated with Lower Socio-Economic Status: Results from a Linked Dataset
Lemstra, Mark, Mackenbach, Johan, Neudorf, Cory, Nannapaneni, Ushasri, Canadian Journal of Public Health
Objective: The purpose of this paper was to use a linked dataset to compare health care utilization rates and costs between income groups in Saskatoon, Canada.
Methods: The Canadian Community Health Survey was linked to hospital, physician and medication data in Saskatoon.
Results: Of 3,688 eligible participants, 3,433 agreed to the health survey and data linkage with health records (83.7% overall response). Low-income residents were 27-33% more likely to be hospitalized and 36-45% more likely to receive a medication than middle- and higher-income residents, but were 5-7% less likely to visit a physician over a one-year period. In comparison to middle-income residents, low-income residents had 56% more high users of hospitals, 166% more high users of physicians and 90% more high users of medications. Low-income residents had 34-35% higher health care costs overall than middle- and high-income residents. After multivariate adjustment for increased disease prevalence, low income had a reduced association with high health care utilization.
Conclusions: The results demonstrate that residents with lower income are responsible for disproportionate usage of hospitals, physicians and medications; due mainly (but not entirely) to higher disease prevalence.
Key words: Delivery of health care; utilization; socioeconomic factors; economics
La traduction du résumé se trouve à la fin de l'article. Can J Public Health 2009;100(3):180-83.
Mots clés : prestation de soins de santé; utilisation; facteurs socioéconomiques; économie
Persistent socio-economic inequalities are a costly economic deadweight in terms of higher expenditures on health care, income assistance, social services, correctional services and lost tax revenue.1 Two reports from Canada and the European Union have concluded that disparities in socio-economic status account for 20% of total health care resources.2,3 The concern, however, with using estimates of self-report health care utilization through telephone surveys is that the recall of 'number of contacts' with health care services does not demonstrate good validity.4
The primary purpose of this paper was to use a linked dataset to compare actual health care utilization rates, high health care utilization patterns and overall costs between income groups in Saskatoon, Canada. The second purpose was to use regression analysis to determine which covariates were independently associated with high health care utilization after controlling for disease prevalence.
The Canadian Community Health Survey (CCHS) is administered by Statistics Canada with the central objective of collecting selfreport health-related data at the level of health regions.5 The CCHS consists of cross-sectional surveys in 2000/01, 2003 and 2005. The methodology of the CCHS has been documented in detail previously. 5
Income status was based on the Low Income Cut-Off (LICO) developed by Statistics Canada.6 Cut-off points are adjusted for family size, population of area of residence, urban/rural differences and consumer price index. For example, a single adult in Saskatoon with an income less than $18,000, and a family of four with an income of less than $33,000, fall below the LICO and are therefore classified as low-income earners. High-income earners were those who made more than $80,000 per year. The remainder were classified as middle-income earners.
The review of health care utilization included hospitals (including emergency room and day surgeries), physicians (including specialists) and prescription medications. Saskatchewan has universal health coverage for all residents, with a centralized administrative database that collects information on all hospital separations, physician visits and medication usage. The positive predictive value of a primary diagnosis from hospital administrative data in Saskatchewan (for stroke) is 90%.7 At the time of the CCHS survey, each respondent was asked to consent to having their self-report survey information linked with their provincial health records. …