Impact of socioeconomic status on end-of-life costs: a systematic review and meta-analysis

Caberry W Yu,David A Alter,S Mohammad Alavinia

doi:10.1186/s12904-020-0538-y

Abstract

BackgroundSocioeconomic inequalities in access to, and utilization of medical care have been shown in many jurisdictions. However, the extent to which they exist at end-of-life (EOL) remains unclear.MethodsStudies in MEDLINE, EMBASE, CINAHL, ProQuest, Web of Science, Web of Knowledge, and OpenGrey databases were searched through December 2019 with hand-searching of in-text citations. No publication date or language limitations were set. Studies assessing SES (e.g. income) in adults, correlated to EOL costs in last year(s) or month(s) of life were selected. Two independent reviewers performed data abstraction and quality assessment, with inconsistencies resolved by consensus.ResultsA total of twenty articles met eligibility criteria. Two meta-analyses were performed on studies that examined total costs in last year of life – the first examined costs without adjustments for confounders (n = 4), the second examined costs that adjusted for confounders, including comorbidities (n = 2). Among studies which did not adjust for comorbidities, SES was positively correlated with EOL costs (standardized mean difference, 0.13 [95% confidence interval, 0.03 to 0.24]). However, among studies adjusting for comorbidities, SES was inversely correlated with EOL expenditures (regression coefficient, −$150.94 [95% confidence interval, −$177.69 to -$124.19], 2015 United States Dollars (USD)). Higher ambulatory care and drug expenditure were consistently found among higher SES patients irrespective of whether or not comorbidity adjustment was employed.ConclusionOverall, an inequality leading to higher end-of-life expenditure for higher SES patients existed to varying extents, even within countries providing universal health care, with greatest differences seen for outpatient and prescription drug costs. The magnitude and directionality of the relationship in part depended on whether comorbidity risk-adjustment methodology was employed.

Highlights

Socioeconomic inequalities in access to, and utilization of medical care have been shown in many jurisdictions
We found that patient socioeconomic status (SES) was significantly correlated with EOL expenditures
In conclusion, our study demonstrated an association between SES was EOL health care expenditures, thereby underscoring the potential importance of SES as a determinant of health and health care delivery inequalities throughout the life-continuum

Summary

Introduction

Socioeconomic inequalities in access to, and utilization of medical care have been shown in many jurisdictions. The extent to which they exist at end-of-life (EOL) remains unclear. Low SES patients have decreased access to needed health care services, even in countries with universal health coverage [8, 9]. The end-of-life (EOL) period represents a period of high health care use, unmeasured differences in medical need across patient populations are thought to be attenuated in the terminal years by virtue of the fact that all such patients die. Differences in EOL expenditures according to SES may represent variations in access to medical care, and yield insights in health care seeking behaviours, location of care, medical decision-making, and health care resource allocation [10].

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