Income is a significant factor in determining why people are hospitalized in Toronto, where the richest and poorest patients are being admitted for very different reasons, a pioneering new study has found.

Whereas more affluent patients are more likely to be hospitalized for surgeries, such as cataract removal and hip replacements, lower-income patients are more commonly treated for mental health issues and non-urgent complaints. They are also more likely to occupy hospital beds while awaiting transfer to nursing homes and other community-based care.

The first of its kind in Toronto -- and possibly Canada -- to investigate the link between income and hospital treatment patterns, the study is intended to provide health care professionals with a more accurate picture of the patients they see.

But according to author Rick Glazier, it also suggests that access to the health care system, however universal, isn’t always equal.

“People with high levels of income, high levels of education, they know how to navigate the system in better ways and are better able and better positioned to take up new technologies, new procedures and get their needs met,” Glazier told The Huffington Post. “So, even within the same hospital we have this big difference of what services are provided.”

10 WAYS INEQUALITY MAY BE MAKING LIFE WORSE

This discrepancy is often on display at St. Michael’s Hospital in downtown Toronto, where Glazier has worked as a family and community services doctor since the 1990s. The hospital runs five family health centres, including one at the 410 Sherbourne, which he says is home to “the most fascinating waiting room in the entire world.”

“We have Bay Street lawyers and homeless people cheek-by-jowl,” he said.

It is this stark contrast -- and the lack of information about the socio-economic status of hospital patients -- that inspired the study, which was a joint effort between researchers at the Centre for Research on Inner City Health at St. Michael's, the Institute for Clinical Evaluative Sciences and the Hospital Collaborative on Marginalized and Vulnerable Populations.

Because hospitals in Canada don’t collect data on patient incomes, the researchers used census information to link postal codes to household incomes for all patients admitted to 20 hospitals in the Toronto Central Local Health Integration Network (LHIN) between 2008 to 2010.

Overall, they found that high and low-income patients were admitted in roughly equal numbers, with middle-income patients being admitted the least. While some hospitals, such as St. Michael’s, treated the same proportion of rich and poor, others had more high or low-income patients.

The services patients accessed varied widely across the income distribution, with the richest patients more likely to be hospitalized for surgeries -- which, as Glazier points out, are often elective -- and investigations like MRIs. The poorest patients, meanwhile, made greater use of emergency departments for low-urgency issues such as upper respiratory infections and minor injuries, as well as chronic conditions like diabetes.

All of which speaks to the big differences in the way that patients along the income spectrum understand and use the hospital system, he says.

“We actually have both extremes, of the over-anxious, overly engaged, and the under-anxious, under-engaged [patients who are] not very good at recognizing when they should come in or what they should do,” he said.

“So we have a lot of work to do, both to try and meet in the middle around what’s the kind of health care that’s able to provide benefit and not harm to people.”

To illustrate just how closely socioeconomic status is tied to health outcomes -- and the treatment plans health professionals provide -- Glazier uses the example of a lower income patient being discharged from a hospital for wound care.

“If you need them to come back to the clinic every few days for a dressing change and they have no means of transportation and they live alone, those are really important things to know, he said. “Your treatment plan is likely to fail if there are people who are unable to be able to carry through with the plan.”

As Glazier sees it, the study is merely a starting point.

Ideally, he says questions related to income -- as well as education and immigration -- should be baked directly into the intake process at every health encounter, and that data should be updated regularly.

“We have less knowledge about our patients that would be useful to have, both at the point of clinical care, and also to understand statistically about who is doing well and who is not doing well,” he said.

10 WAYS INEQUALITY MAY BE MAKING LIFE WORSE

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  • Health

    According to <a href="http://www.equalitytrust.org.uk/" target="_hplink">data compiled by the Equality Trust</a>, Americans living in more economically equal states live four years longer, on average, than Americans in less equal states. That trend holds true for the developed world as a whole. This chart shows the correlation between infant deaths and income inequality across the developed world.

  • Health

    According to <a href="http://www.equalitytrust.org.uk/" target="_hplink">data compiled by the Equality Trust</a>, Americans living in more economically equal states live four years longer, on average, than Americans in less equal states. That trend holds true for the developed world as a whole. This chart shows the correlation between infant deaths and income inequality across the developed world.

  • Mental Health

    Data from the World Health Organization, <a href="http://www.equalitytrust.org.uk" target="_hplink">compiled by the Equality Trust</a>, shows a strong correlation between incidences of mental illness and a country's relative income gap. In this comparison of 12 developed countries, the U.S. has the highest income inequality and the highest rate of mental illness.

  • Mental Health

    Data from the World Health Organization, <a href="http://www.equalitytrust.org.uk" target="_hplink">compiled by the Equality Trust</a>, shows a strong correlation between incidences of mental illness and a country's relative income gap. In this comparison of 12 developed countries, the U.S. has the highest income inequality and the highest rate of mental illness.

  • Drug Abuse

    Data from the UN's World Drug Report 2007, compiled by the Equality Trust, shows a link between a country's income gap and drug use. The correlation isn't perfect -- Australia has higher drug use rates than the U.S., while having a significantly smaller income gap -- but it does show that Europe's more economically equal countries enjoy considerably lower illicit drug use rates. The Equality Trust also found a similar link in drug use rates within U.S. states.

  • Drug Abuse

    Data from the UN's World Drug Report 2007, compiled by the Equality Trust, shows a link between a country's income gap and drug use. The correlation isn't perfect -- Australia has higher drug use rates than the U.S., while having a significantly smaller income gap -- but it does show that Europe's more economically equal countries enjoy considerably lower illicit drug use rates. The Equality Trust also found a similar link in drug use rates within U.S. states.

  • Education

    The quality of school systems is important but the most important factor in determining education outcomes is family background, reports the Equality Trust. In that light, it's clear why income inequality would affect educational attainment: In places where struggling families have the least support, this translates into worse educational outcomes. This chart comparing U.S. states shows a strong correlation between the income gap and high school dropout rates.

  • Education

    The quality of school systems is important but the most important factor in determining education outcomes is family background, reports the Equality Trust. In that light, it's clear why income inequality would affect educational attainment: In places where struggling families have the least support, this translates into worse educational outcomes. This chart comparing U.S. states shows a strong correlation between the income gap and high school dropout rates.

  • Imprisonment

    A study published in Social Sciences and Medicine found a strong correlation between U.S. states with high income inequality and imprisonment rates. Countries that have large differences between rich and poor tend to incarcerate criminals for longer periods than those with smaller income gaps. The Equality Trust notes that <a href="http://www.equalitytrust.org.uk/why/evidence/imprisonment" target="_hplink">this holds true even among U.S. states</a> -- Louisiana incarcerates at six times the rate of Minnesota.

  • Imprisonment

    A study published in Social Sciences and Medicine found a strong correlation between U.S. states with high income inequality and imprisonment rates. Countries that have large differences between rich and poor tend to incarcerate criminals for longer periods than those with smaller income gaps. The Equality Trust notes that <a href="http://www.equalitytrust.org.uk/why/evidence/imprisonment" target="_hplink">this holds true even among U.S. states</a> -- Louisiana incarcerates at six times the rate of Minnesota.

  • Obesity

    The obesity epidemic sweeping the developed world could be the first medical issue to reduce life expectancy in wealthy countries in more than a century, the Equality Trust says. The Trust found a correlation between obesity rates and income inequality across the developing world, with childhood obesity also correlated to the income gap in a given country or U.S. state.

  • Obesity

    The obesity epidemic sweeping the developed world could be the first medical issue to reduce life expectancy in wealthy countries in more than a century, the Equality Trust says. The Trust found a correlation between obesity rates and income inequality across the developing world, with childhood obesity also correlated to the income gap in a given country or U.S. state.

  • Social Mobility

    Studies have shown that Americans tend to believe their country has a high rate of social mobility -- the ability to improve your economic situation -- while Europeans tend to have less faith in it. The evidence suggests it should be reversed -- those European countries with smaller income gaps actually have greater economic and social mobility, while in the U.S., and other countries with high income gaps, going from rags-to-riches is more difficult.

  • Social Mobility

    Studies have shown that Americans tend to believe their country has a high rate of social mobility -- the ability to improve your economic situation -- while Europeans tend to have less faith in it. The evidence suggests it should be reversed -- those European countries with smaller income gaps actually have greater economic and social mobility, while in the U.S., and other countries with high income gaps, going from rags-to-riches is more difficult.

  • Violent Crime

    According to the Equality Trust, there are more than 40 studies showing a link between inequality and violent crime. "The most important reason why violence is more common in more unequal societies is that <a href="http://www.equalitytrust.org.uk/why/evidence/violence" target="_hplink">it is often triggered by people feeling looked down, disrespected and loss of face</a>," the Trust argues. This chart shows a ten-fold difference in murder rates between developed countries.

  • Violent Crime

    According to the Equality Trust, there are more than 40 studies showing a link between inequality and violent crime. "The most important reason why violence is more common in more unequal societies is that <a href="http://www.equalitytrust.org.uk/why/evidence/violence" target="_hplink">it is often triggered by people feeling looked down, disrespected and loss of face</a>," the Trust argues. This chart shows a ten-fold difference in murder rates between developed countries.

  • Teen Pregnancy

    There is a strong correlation between income inequality in countries and the birth rate for teenage girls. This chart shows the U.S. teen birth rate at a particularly high level, but differences in abortion rates between countries mean it's hard to tell how this correlates to teen pregnancies.

  • Teen Pregnancy

    There is a strong correlation between income inequality in countries and the birth rate for teenage girls. This chart shows the U.S. teen birth rate at a particularly high level, but differences in abortion rates between countries mean it's hard to tell how this correlates to teen pregnancies.

  • Child Well-Being

    A recent UNICEF study that tracked 40 indicators of childhood well-being found a correlation between income inequality and the standard of living for children. Interestingly, the Equality Trust argues that, at this point, further economic growth won't address this issue. "<a href="http://www.equalitytrust.org.uk/why/evidence/child-well-being" target="_hplink">Improvements in child wellbeing in rich societies will depend more on reductions in inequality than on further economic growth</a>," the Trust argues.

  • Child Well-Being

    A recent UNICEF study that tracked 40 indicators of childhood well-being found a correlation between income inequality and the standard of living for children. Interestingly, the Equality Trust argues that, at this point, further economic growth won't address this issue. "<a href="http://www.equalitytrust.org.uk/why/evidence/child-well-being" target="_hplink">Improvements in child wellbeing in rich societies will depend more on reductions in inequality than on further economic growth</a>," the Trust argues.


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