"Bring the Hoses to Where the Fire Is!": Differential Impacts of Marginalization and Socioeconomic Status on COVID-19 Case Counts and Healthcare Costs

Douglas C Cheung; Karen E Bremner; Teresa C O Tsui; Ruth Croxford; Lauren Lapointe-Shaw; Lisa Del Giudice; Andrew Mendlowitz; Nathan Perlis; Reka E Pataky; Paulos Teckle; Seraphine Zeitouny; William W L Wong; Beate Sander; Stuart Peacock; Murray D Krahn; Girish S Kulkarni; Carol Mulder

doi:10.1016/j.jval.2022.03.019

"Bring the Hoses to Where the Fire Is!": Differential Impacts of Marginalization and Socioeconomic Status on COVID-19 Case Counts and Healthcare Costs

Value Health. 2022 Aug;25(8):1307-1316. doi: 10.1016/j.jval.2022.03.019. Epub 2022 May 6.

Authors

Douglas C Cheung¹, Karen E Bremner², Teresa C O Tsui³, Ruth Croxford⁴, Lauren Lapointe-Shaw⁵, Lisa Del Giudice⁶, Andrew Mendlowitz⁷, Nathan Perlis⁸, Reka E Pataky⁹, Paulos Teckle⁹, Seraphine Zeitouny¹⁰, William W L Wong¹¹, Beate Sander¹², Stuart Peacock¹³, Murray D Krahn¹⁴, Girish S Kulkarni¹⁵, Carol Mulder¹⁶

Affiliations

¹ Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada; Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Surgical Oncology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
² Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.
³ Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
⁴ ICES, Toronto, Ontario, Canada.
⁵ Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; General Internal Medicine, Toronto General Hospital, Toronto, Ontario, Canada.
⁶ Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
⁷ Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
⁸ Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
⁹ Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.
¹⁰ Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada.
¹¹ Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada; School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada.
¹² Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Public Health Ontario, Toronto, Ontario, Canada.
¹³ Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
¹⁴ Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; General Internal Medicine, Toronto General Hospital, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
¹⁵ Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Surgical Oncology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
¹⁶ Chiefs of Ontario, Toronto, Ontario, Canada; Queen's University, Kingston, Ontario, Canada. Electronic address: carol.mulder@coo.org.

Abstract

Objectives: Local health leaders and the Director General of the World Health Organization alike have observed that COVID-19 "does not discriminate." Nevertheless, the disproportionate representation of people of low socioeconomic status among those infected resembles discrimination. This population-based retrospective cohort study examined COVID-19 case counts and publicly funded healthcare costs in Ontario, Canada, with a focus on marginalization.

Methods: Individuals with their first positive severe acute respiratory syndrome coronavirus 2 test from January 1, 2020 to June 30, 2020, were linked to administrative databases and matched to negative/untested controls. Mean net (COVID-19-attributable) costs were estimated for 30 days before and after diagnosis, and differences among strata of age, sex, comorbidity, and measures of marginalization were assessed using analysis of variance tests.

Results: We included 28 893 COVID-19 cases (mean age 54 years, 56% female). Most cases remained in the community (20 545, 71.1%) or in long-term care facilities (4478, 15.5%), whereas 944 (3.3%) and 2926 (10.1%) were hospitalized, with and without intensive care unit, respectively. Case counts were skewed across marginalization strata with 2 to 7 times more cases in neighborhoods with low income, high material deprivation, and highest ethnic concentration. Mean net costs after diagnosis were higher for males ($4752 vs $2520 for females) and for cases with higher comorbidity ($1394-$7751) (both P < .001) but were similar across levels of most marginalization dimensions (range $3232-$3737, all P ≥ .19).

Conclusions: This study suggests that allocating resources unequally to marginalized individuals may improve equality in outcomes. It highlights the importance of reducing risk of COVID-19 infection among marginalized individuals to reduce overall costs and increase system capacity.

Keywords: COVID-19; Canada; costs and costs analyses; marginalization; socioeconomic status; universal healthcare.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

COVID-19* / epidemiology
Female
Health Care Costs
Humans
Male
Middle Aged
Ontario / epidemiology
Retrospective Studies
Social Class

Grants and funding

VR4 172774/CIHR/Canada