Abstract
Background
Numerous studies have established that socio-economic position is positively related to health status, but we know little about the real costs of these differences across an entire population. This paper estimates the potential savings in morbidity and dollars from reducing the inequalities in health among Winnipeg residents.
Methods
We measure excess morbidity by examining rates of premature death, hip fracture, and heart attack according to the relative affluence of the Winnipeg neighbourhood. We also assess the total expenditures on physician and hospital care by neighbourhood of residence. We then estimate the savings that could have been achieved if 1) the health of the two poorest quintiles had been raised to the level of the middle quintile, and 2) the health of the poorest four quintiles had been raised to the level of the top quintile.
Results
Thirty-seven percent of Winnipeg’s premature deaths, 22% of the heart attacks, 20% of the hip fractures and 15% of total expenditures on hospitals and physicians ($62 million in 1 999 dollars) could have been avoided if residents of the less wealthy 80% of neighbourhoods enjoyed health similar to those in the wealthiest neighbourhoods.
Conclusion
The potential savings from reducing the socio-economic-related differences in health are high, whether they are measured in terms of morbidity or dollars. Research is needed to determine the extent to which these potential savings are achievable.
Résumé
Contexte
De nombreuses études ont confirmé l’existence d’un lien positif entre le statut socio-économique et l’état de santé, mais on sait très peu de choses sur les coûts réels des écarts socio-économiques à l’échelle d’une population. Nous avons voulu évaluer les économies possibles, en morbidité et en argent, d’une réduction des inégalités sur le plan de la santé dans la population de Winnipeg.
Méthode
Nous avons mesuré la surmorbidité en examinant les taux de décès prématurés, de fractures de la hanche et de crises cardiaques selon l’aisance relative des quartiers de Winnipeg. Nous avons aussi analysé les dépenses totales en soins médicaux et hospitaliers selon le quartier de résidence. Enfin, nous avons évalué les économies qui auraient pu être réalisées: 1) si la santé dans les deux quintiles les plus pauvres était haussée au niveau de celle du quintile intermédiaire et 2) si la santé dans les quatre quintiles les plus pauvres était haussée au niveau de celle du quintile supérieur.
Résultats
À Winnipeg, 37 % des décès prématurés, 22 % des crises cardiaques, 20 % des fractures de la hanche et 15 % des dépenses totales en soins hospitaliers et médicaux (62 millions, en dollars de 1999) auraient pu être évités si l’état de santé des résidents des quartiers les moins aisés (80 %) était le même que dans les quartiers les plus aisés.
Conclusion
Il serait possible de réaliser d’importantes économies (qu’elles soient mesurées en morbidité ou en argent) en réduisant les écarts sur le plan de la santé liés au statut socio-économique. Il faudrait pousser la recherche pour déterminer la mesure dans laquelle de telles économies seraient réalisables.
References
- 1.DHHS. Inequalities in health: A report of a research working group. London: DHSS; 1980. [Google Scholar]
- 2.Gorey KM, Holowaty EJ, Laukkanen E, Fehringer G, Richter NL. An international comparison of cancer survival: Advantage of Toronto’s poor over the near poor of Detroit. Can J Public Health. 1998;89(2):102–4. doi: 10.1007/BF03404398. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lundberg O. Causal explanations for class inequality and health: An empirical analysis. Soc Sci Med. 1991;32:385. doi: 10.1016/0277-9536(91)90339-E. [DOI] [PubMed] [Google Scholar]
- 4.Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med. 1993;329(2):103–9. doi: 10.1056/NEJM199307083290207. [DOI] [PubMed] [Google Scholar]
- 5.Stamler R, Hardy RJ. Educational level and 5-year all-cause mortality in the hypertension detection and follow-up program. Hypertension. 1987;9:641. doi: 10.1161/01.HYP.9.6.641. [DOI] [PubMed] [Google Scholar]
- 6.Vagero D. Inequality in health — Some theoretical and empirical problems. Soc Sci Med. 1991;32:367. doi: 10.1016/0277-9536(91)90337-C. [DOI] [PubMed] [Google Scholar]
- 7.Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Board on Health Sciences Policy, Institute of Medicine, 2003, https://doi.org/www.nap.edu/books/030908265X/html.
- 8.U.S. General Accounting Office. Public Health: A health status indicator for targeting federal aid to states. 1996. [Google Scholar]
- 9.Kindig D. Purchasing Population Health: Paying for Results. Ann Arbor, MI: The University of Michigan Press; 1997. [Google Scholar]
- 10.Mays N, Chinn S, Ho K. Interregional variations in measures of health from the health and lifestyle survey and their relation with indicators of health care need. J Epidemiol Community Health. 1992;46:38–47. doi: 10.1136/jech.46.1.38. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Reid RJ, Roos NP, MacWilliam L, Frohlich N, Black C. Assessing population need using a claims-based ACG morbidity measure: A validation analysis in the province of Manitoba. Health Serv Res. 2002;37(5):1345–64. doi: 10.1111/1475-6773.01029. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Wennberg JE, Freeman J, Culp W. Are hospital services rationed in New Haven or over-utilized in Boston? Lancet. 1987;1(8543):1185–88. doi: 10.1016/S0140-6736(87)92152-0. [DOI] [PubMed] [Google Scholar]
- 13.Wennberg JE, Cooper MM. The Quality of Medical Care in the United States: A report on the Medicare Program, The Dartmouth Atlas of Health Care in the United States. Chicago: American Hospital Publishing Inc.; 1999. Variations, Patient Need, Practice Style and Hospital Capacity. [PubMed] [Google Scholar]
- 14.Canadian Institute for Health Information. DAD Resource Indicators for Use with Complexity. 1999. [Google Scholar]
- 15.Finlayson G, Roos NP, Jacobs P, Watson D. Using the Manitoba Hospital Management Information System: Comparing Average Cost Per Weighted Case and Financial Ratios of Manitoba Hospitals (1997/98) Winnipeg: Manitoba Centre for Health Policy; 2001. [Google Scholar]
- 16.Roos LL, Sharp SM, Cohen MM. Comparing clinical information with claims data: Some similarities and differences. J Clin Epidemiol. 1991;44(9):881–88. doi: 10.1016/0895-4356(91)90050-J. [DOI] [PubMed] [Google Scholar]
- 17.Roos LL, Nicol J, Cageorge S. Using administrative data for longitudinal research: Comparisons with primary data collection. J Chron Dis. 1987;40(1):41–49. doi: 10.1016/0021-9681(87)90095-6. [DOI] [PubMed] [Google Scholar]
- 18.Roos LL, Sharp SM, Wajda A. Assessing data quality: A computerized approach. Soc Sci Med. 1989;28(2):175–82. doi: 10.1016/0277-9536(89)90145-7. [DOI] [PubMed] [Google Scholar]
- 19.Manga P, Broyles R, Angus D. The determinants of hospital utilization under a universal public insurance programme in Canada. Med Care. 1987;25:658–70. doi: 10.1097/00005650-198707000-00009. [DOI] [PubMed] [Google Scholar]
- 20.Siemiatycki J, Richardson L, Pless IB. Equality in medical care under national health insurance in Montreal. N Engl J Med. 1980;303:10–15. doi: 10.1056/NEJM198007033030103. [DOI] [PubMed] [Google Scholar]
- 21.Haan M, Kaplan GA, Camacho T. Poverty and health: Prospective evidence from the Alameda County Study. Am J Epidemiol. 1987;125:989. doi: 10.1093/oxfordjournals.aje.a114637. [DOI] [PubMed] [Google Scholar]
- 22.Carstairs V, Morris R. Deprivation: Explaining differences in mortality between Scotland, England and Wales. BMJ. 1989;29:866–89. doi: 10.1136/bmj.299.6704.886. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Keskimaki I, Salinto M, Aro S. Socioeconomic equity in Finnish hospital care in relation to need. Soc Sci Med. 1995;41:425. doi: 10.1016/0277-9536(94)00339-U. [DOI] [PubMed] [Google Scholar]
- 24.Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United States, 1998. Hyattsville: National Center for Health Statistics; 1998. [Google Scholar]
- 25.Marmot M. Multilevel approaches to understanding social determinants. In: Berkman LF, Kawachi I, editors. Social Epidemiology. London, England: Oxford University Press; 2000. pp. 349–67. [Google Scholar]
- 26.Mustard CA, Derksen S, Berthelot J-M, Wolfson M. Assessing ecologic proxies for household income: A comparison of household and neighbourhood level income measures in the study of population health status. Health and Place. 1999;5(2):157–71. doi: 10.1016/S1353-8292(99)00008-8. [DOI] [PubMed] [Google Scholar]
- 27.Krieger N. Women in social class: A methodologie study comparing individual, household and census measures as predictors of black/white differences in reproductive history. J Clin Epidemiol Community Health. 1991;45:35–42. doi: 10.1136/jech.45.1.35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Diez Roux AV, Nieto FJ, Muntaner C, Tyroler HA, Comstock GW, Shahar E, et al. Neighborhood environments and coronary heart disease: A multilevel analysis. Am J Epidemiol. 1997;146(1):48–62. doi: 10.1093/oxfordjournals.aje.a009191. [DOI] [PubMed] [Google Scholar]
- 29.Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health? J Epidemiol Community Health. 2003;57:424–28. doi: 10.1136/jech.57.6.424. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Finkelstein M. Ecologie proxies for household income: How well do they work for the analysis of health and health care utilization? Can J Public Health. 2004;95(2):90–94. doi: 10.1007/BF03405773. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Mustard CA, Finlayson M, Derksen S, Berthelot J-M. What determines the need for nursing home admission in a universally insured system. J Health Serv Res Policy. 1999;4:197–203. doi: 10.1177/135581969900400403. [DOI] [PubMed] [Google Scholar]
- 32.Roos NP, Stranc L, Peterson S, Mitchell L, Bogdanovic B, Shapiro E. A look at home care in Manitoba. Winnipeg, MB: Manitoba Centre for Health Policy; 2001. [Google Scholar]
- 33.Metge C, Black C, Peterson S, Kozyrskyj A. The population’s use of pharmaceuticals. Med Care. 1999;37:JS42–JS59. doi: 10.1097/00005650-199906001-00008. [DOI] [PubMed] [Google Scholar]
- 34.Gupta S, Roos LL, Walld R, Traverse D, Dahl M. Delivering equitable care: Comparing preventive services in Manitoba. Am J Public Health. 2003;93(12):2086–92. doi: 10.2105/AJPH.93.12.2086. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Mechanic D. Disadvantage, inequality, and social policy. Health Affairs. 2002;21:48–59. doi: 10.1377/hlthaff.21.2.48. [DOI] [PubMed] [Google Scholar]
- 36.Roos NP, Mustard CA. Variation in health and health care use by socioeconomic status in Winnipeg, Canada: Does the system work well? Yes and no. Milbank Q. 1997;75:89–111. doi: 10.1111/1468-0009.00045. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Manton K. The dynamics of population aging: Demography and policy analysis. Milbank Q. 1991;69(2):309–38. doi: 10.2307/3350207. [DOI] [PubMed] [Google Scholar]
- 38.Bailar JC, Gornik HL. Cancer undefeated. N Engl J Med. 1997;336:1569–1574. doi: 10.1056/NEJM199705293362206. [DOI] [PubMed] [Google Scholar]
- 39.Tsevat J, Weinstein M, Williams W, Tosteson A, Goldman L. Expected gains in life expectancy from various coronary heart disease risk factor modifications. Circulation. 1991;83:1194–201. doi: 10.1161/01.CIR.83.4.1194. [DOI] [PubMed] [Google Scholar]
- 40.Roos NP, Forget E, Walld R, MacWilliam L. Does universal comprehensive insurance coverage encourage unnecessary use? Evidence from Manitoba says “no”. CMAJ. 2004;170(2):209–14. [PMC free article] [PubMed] [Google Scholar]