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Concept: Quintile


US medical spending growth slowed between 2004 and 2013. At the same time, many Americans faced rising copayments and deductibles, which may have particularly affected lower-income people. To explore whether the health spending slowdown affected all income groups equally, we divided the population into income quintiles. We then assessed trends in health expenditures by and on behalf of people in each quintile using twenty-two national surveys carried out between 1963 and 2012. Before the 1965 passage of legislation creating Medicare and Medicaid, the lowest income quintile had the lowest expenditures, despite their worse health compared to other income groups. By 1977 the unadjusted expenditures for the lowest quintile exceeded those for all other income groups. This pattern persisted until 2004. Thereafter, expenditures fell for the lowest quintile, while rising more than 10 percent for the middle three quintiles and close to 20 percent for the highest income quintile, which had the highest expenditures in 2012. The post-2004 divergence of expenditure trends for the wealthy, middle class, and poor occurred only among the nonelderly. We conclude that the new pattern of spending post-2004, with the wealthiest quintile having the highest expenditures for health care, suggests that a redistribution of care toward wealthier Americans accompanied the health spending slowdown.

Concepts: Health care, Poverty, Household income in the United States, Wealth, Working class, Quintile, Upper middle class, American middle class


Due to a persistent discrepancy between the demand for liver transplantation and the supply of deceased donor organs, there is an interest in increasing live donation rates at centres trained in this method of transplantation. We examined a large socioeconomically heterogeneous cohort of patients listed for liver transplantation to identify recipient factors associated with live donation. We retrospectively reviewed 491 consecutive patients who were listed for liver transplantation at our centre over a 24 month period. Demographic, medical, and socioeconomic data were extracted from electronic records and compared between those who had a potential live donor volunteer for assessment, and those who did not. 245 patients (50%) had at least one potential live donor volunteer for assessment. Multivariate logistic regression analysis identified that patients with a live donor were more likely to have Child-Pugh C disease (OR 2.44, p=0.019), and less likely to be older (OR 0.96, p=0.002), single (OR 0.34, p=0.006), divorced (OR 0.53, p=0.03), immigrants (OR 0.38, p=0.049) or from the lowest income quintile (OR 0.44, p=0.016).

Concepts: Regression analysis, Logistic regression, Demography, Actuarial science, Liver, Organ transplant, Socioeconomics, Quintile


Objective: Climate change is affecting the ability of food systems to provide sufficient nutritious and affordable foods at all times. Healthy and sustainable (H&S) food choices are important contributions to health and climate change policy efforts. This paper presents empirical data on the affordability of a food basket that incorporates principles of health and sustainability across different food sub-systems, socioeconomic neighbourhoods and household income levels in Greater Western Sydney, Australia. Methods: A basket survey was used to investigate the cost of both a typical basket of food and a hypothetical H&S basket. The price of foods in the two baskets was recorded in five neighbourhoods, and the affordability of the baskets was determined across household income quintiles. Results: The cost of the H&S basket was more than the typical basket in all five socioeconomic neighbourhoods, with most disadvantaged neighbourhood spending proportionately more (30%) to buy the H&S basket. Within household income levels, the greatest inequity was found in the middle income neighbourhood, showing that households in the lowest income quintile would have to spend up to 48% of their weekly income to buy the H&S basket, while households in the highest income quintile would have to spend significantly less of their weekly income (9%). Conclusion: The most disadvantaged groups in the region, both at the neighbourhood and household level, experience the greatest inequality in affordability of the H&S diet. Implications: The results highlight the current inequity in food choice in the region and the underlying social issues of cost and affordability of H&S foods.

Concepts: Nutrition, Household, Sustainability, Household income in the United States, Income quintiles, Income in the United States, Quintile, Upper middle class


Background The objective was to compare 5-year overall survival (OS) between adolescent and young adult (AYA) patients (age 15-19) with acute lymphoblastic leukemia (ALL) treated at a pediatric versus an adult center. Patients and methods This was a population-based analysis using administrative data of Ontario ALL AYA patients diagnosed between 1986-2009. We calculated predicted survival proportions (PSPs) and 95% confidence intervals (CI). We also surveyed sites to determine whether pediatric or adult-based protocols were used in each period. Results Overall, 290 patients between 15-19 years of age were diagnosed with ALL during the study period; 144 patients (49.7%) were treated at an adult center. When adjusted for gender, age, income quintile and time period, AYA patients treated at a pediatric center did not have a significantly different PSP (0.65, 95% CI: 0.56-0.75) in comparison to those treated at an adult center (0.62, 95% CI 0.52-0.73; P = 0.87). Most AYA patients treated at adult centers received pediatric protocols in the recent periods. Conclusions Using population-based data, AYA ALL patients had similar outcomes whether treated at a pediatric or an adult center. Early introduction of aggressive treatment protocols in adult centers may have negated differences in outcomes among AYA patients by site of care.

Concepts: Comparison, Physician, Urgent care, Adolescence, Acute lymphoblastic leukemia, Prediction interval, Period, Quintile


AIMS: Diabetes rates are increasing dramatically, and certain populations are at greater risk. Low income status is associated with higher diabetes prevalence and higher mortality. The effect of income on diabetes incidence is less well understood. METHODS: Using a validated, population-based diabetes registry and census data from Ontario, Canada, we compared the rate of new diabetes cases among persons aged 20 years or older between April 1st 2006 and March 31st 2007between neighborhood income quintiles, and assessed for age- and sex-based differences. RESULTS: There were 88,886 new cases of diabetes in Ontario adults during our study period (incidence rate 8.26/1000, 95% confidence interval, CI 8.20-8.31). Rates increased with age and were higher in males versus females. Increasing income quintile was associated with a significantly decreased diabetes incidence (8.70/1000, 95% CI 8.57-8.82 in the lowest quintile, vs. 7.25/1000, 95% CI 7.14-7.36 in the highest quintile, p<0.0001). Significant interactions were found between income quintile (1, 2, and 3 vs. 5) and age groups (20-39, 40-59 vs. 80+ years) (p<0.01) and sex (p<0.01), such that the impact of income was more pronounced in younger compared to older age groups and in females versus males. DISCUSSION: This population-based study found that diabetes risk is significantly higher in lower compared to higher income groups, and that this income gap was widest in younger persons and females. Greater diabetes preventive efforts directed toward younger and female lower-income populations are necessary, in order to lessen the lifelong burden of diabetes for an already disadvantaged population.

Concepts: Male, Female, Medical statistics, Population, Incidence, Sex, Household income in the United States, Quintile


The incidence of esophageal adenocarcinoma (EAC) is increasing worldwide and has overtaken squamous histology in occurrence. We studied the impact of socioeconomic status (SES) on EAC stage at diagnosis, receipt of treatment, and survival. A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data. Multinomial logistic regression was used to examine the association between SES (income quintile) and stage at EAC diagnosis and EAC treatment. Survival times following EAC diagnosis were estimated using Kaplan-Meier method. Cox proportional-hazards regression analysis was used to examine the association between SES and EAC survival. Between 2003-2012, 2,125 EAC cases were diagnosed. Median survival for the lowest-SES group was 10.9 months compared to 11.6 months for the highest-SES group; the 5-year survival was 9.8% vs. 15.0%. Compared to individuals in the highest-SES group, individuals in the lowest-SES category experienced no significant difference in EAC treatment (91.6% vs. 93.3%, P = 0.314) and deaths (78.9% vs. 75.6%, P = 0.727). After controlling for covariates, no significant associations were found between SES and cancer stage at diagnosis and EAC treatment. Additionally, after controlling for age, gender, urban/rural residence, birth country, health region, aggregated diagnosis groups, cancer stage, treatment, and year of diagnosis, no significant association was found between SES and EAC survival. Moreover, increased mortality risk was observed among those with older age (P = 0.001), advanced-stage of EAC at diagnosis (P < 0.001), and those receiving chemotherapy alone, radiotherapy alone, or surgery plus chemotherapy (P < 0.001). Adjusted proportional-hazards model findings suggest that there is no association between SES and EAC survival. While the unadjusted model suggests reduced survival among individuals in lower income quintiles, this is no longer significant after adjusting for any covariate. Additionally, there is an apparent association between SES and survival when considering only those individuals diagnosed with stage 0-III EAC. These analyses suggest that the observed direct relationship between SES and survival is explained by patient-level factors including receipt of treatment, something that is potentially modifiable.

Concepts: Regression analysis, Cohort study, Cancer, Lung cancer, Cancer staging, Squamous cell carcinoma, Multinomial logit, Quintile


The aims of this study were to evaluate the influence of socioeconomic status (SES) on time-to-surgery (TTS) and surgical outcome in children with treatment-resistant epilepsy in a universal health care system. The cohort consisted of children who had undergone resective epilepsy surgery between 2001 and 2013 in Canada. The patients' postal codes were linked to Statistics Canada National Household Survey data to obtain dissemination area income, which was used to infer SES. Time-to-surgery was defined as the interval from date of epilepsy onset to date of surgery. Seizure outcome was classified using ILAE classification. The associations between SES and TTS, as well as SES and surgical outcome, were assessed. Two hundred eighty-four children who had epilepsy surgery were included. Patients in the lowest income quintile had a significantly higher TTS relative to the highest income quintile (β=0.121, p=0.044). There were no significant associations between income quintiles and seizure-free surgical outcome (odds ratio (OR)=0.746-1.494, all p>0.05). However, patients in the lowest income quintile had a significantly lower odds of an improvement in seizure frequency relative to the highest income quintile (OR=0.262, p=0.046). The TTS was not uniform across SES in spite of the existence of a universal health care system. This finding highlights the need to address social and economic barriers for epilepsy surgery to improve access to this potentially curative treatment. Those with lower SES had lower likelihood of improvement in seizure control following epilepsy surgery and may require additional support including social and financial support to mitigate the discrepancies in seizure control following surgery between SES levels.

Concepts: Medicine, Universal health care, Socioeconomic status, Physician, Household, Household income in the United States, Income quintiles, Quintile


The impact of socioeconomic status (SES) upon childhood cancer outcomes has not been extensively examined. Our objective was to determine the association between SES and event-free survival (EFS) among children with acute lymphoblastic leukemia (ALL) diagnosed in Ontario, Canada from 1995-2011 (N=1541) using Cox proportional hazards. Neither neighborhood-level median income quintile, distance from tertiary center, or rural residence significantly predicted EFS in the context of a universal healthcare system. Immigrant children experienced significantly superior EFS; confounding by ethnicity could not be ruled out. Confirmatory studies using additional individual-level SES variables are warranted.

Concepts: Cohort study, Medicine, Experimental design, Clinical trial, Leukemia, Acute lymphoblastic leukemia, Household income in the United States, Quintile


Objectives. We explored differences in health and education outcomes between children living in social housing and not, and effects of social housing’s neighborhood socioeconomic status. Methods. In this cohort study, we used the population-based repository of administrative data at the Manitoba Centre for Health Policy. We included children aged 0 to 19 years in Winnipeg, Manitoba, in fiscal years 2006-2007 to 2008-2009 (n = 13 238 social housing; n = 174 017 others). We examined 5 outcomes: age-2 complete immunization, a school-readiness measure, adolescent pregnancy (ages 15-19 years), grade-9 completion, and high-school completion. Logistic regression and generalized estimating equation modeling generated rates. We derived neighborhood income quintiles (Q1 lowest, Q5 highest) from average household income census data. Results. Children in social housing fared worse than comparative children within each neighborhood income quintile. When we compared children in social housing by quintile, preschool indicators (immunization and school readiness) were similar, but adolescent outcomes (grade-9 and high-school completion, adolescent pregnancy) were better in Q3 to Q5. Conclusions. Children in social housing had poorer health and education outcomes than all others, but living in social housing in wealthier areas was associated with better adolescent outcomes. (Am J Public Health. Published online ahead of print September 11, 2014: e1-e11. doi:10.2105/AJPH.2014.302133).

Concepts: Regression analysis, Poverty in the United States, Household, Household income in the United States, Income quintiles, Teenage pregnancy, Quintile


Despite a reported socioeconomic gradient in health, little is known about relationship between socioeconomic status (SES) and frequency of dog-bite injuries. The primary objective of this study was to compare the frequency of dog-bite injuries, using data on dog-bite injury hospitalizations (DBIH), across different SES areas in Manitoba, Canada. The secondary objective of the study was to assess if frequency and pattern of DBIHs are similar to those of non-canine bite injury hospitalizations (NCBIH) and rabies post-exposure prophylaxis (PEP). SES grouping in this study was defined through rurality and area-wide income quintile groups.

Concepts: Socioeconomic status, Injuries, Injury, Knowledge, Rabies, Household income in the United States, Quintile