Looking Beyond Income and Education: Socioeconomic Status Gradients Among Future High-Cost Users of Health Care

Am J Prev Med. 2015 Aug;49(2):161-71. doi: 10.1016/j.amepre.2015.02.018. Epub 2015 May 8.


Introduction: Healthcare spending occurs disproportionately among a very small portion of the population. Research on these high-cost users (HCUs) of health care has been overwhelmingly cross-sectional in nature and limited to the few sociodemographic and clinical characteristics available in health administrative databases. This study is the first to bridge this knowledge gap by applying a population health lens to HCUs. We investigate associations between a broad range of SES characteristics and future HCUs.

Methods: A cohort of adults from two cycles of large, nationally representative health surveys conducted in 2003 and 2005 was linked to population-based health administrative databases from a universal healthcare plan for Ontario, Canada. Comprehensive person-centered estimates of annual healthcare spending were calculated for the subsequent 5 years following interview. Baseline HCUs (top 5%) were excluded and healthcare spending for non-HCUs was analyzed. Adjusted for predisposition and need factors, the odds of future HCU status (over 5 years) were estimated according to various individual, household, and neighborhood SES factors. Analyses were conducted in 2014.

Results: Low income (personal and household); less than post-secondary education; and living in high-dependency neighborhoods greatly increased the odds of future HCUs. After adjustment, future HCU status was most strongly associated with food insecurity, personal income, and non-homeownership. Living in highly deprived or low ethnic concentration neighborhoods also increased the odds of becoming an HCU.

Conclusions: Findings suggest that addressing social determinants of health, such as food and housing security, may be important components of interventions aiming to improve health outcomes and reduce costs.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Databases, Factual
  • Delivery of Health Care
  • Female
  • Health Care Costs / trends*
  • Health Services / economics
  • Health Services / statistics & numerical data*
  • Health Services Needs and Demand / economics*
  • Health Surveys
  • Humans
  • Male
  • Middle Aged
  • Ontario
  • Poverty
  • Risk Factors
  • Socioeconomic Factors
  • Young Adult