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

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

Author information

  • 1Public Health Ontario.
  • 2Public Health Ontario; Institute for Clinical Evaluative Sciences; Dalla Lana School of Public Health. Electronic address:
  • 3Institute for Clinical Evaluative Sciences.
  • 4Healthy Debate; St Michael's Hospital.
  • 5St Michael's Hospital; Centre for Research on Inner City Health.
  • 6Public Health Ontario; Dalla Lana School of Public Health.
  • 7Public Health Ontario; Institute for Clinical Evaluative Sciences; Dalla Lana School of Public Health; Institute of Health Management Policy and Evaluation, University of Toronto.
  • 8Institute for Clinical Evaluative Sciences; Institute of Health Management Policy and Evaluation, University of Toronto; Toronto Rehabilitation Institute, Toronto, Ontario, Canada.



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.


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.


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.


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.

Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

[PubMed - indexed for MEDLINE]
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