Associations Between Socioeconomic Status, Patient Risk, and Short-Term Intensive Care Outcomes

Abstract

OBJECTIVES: To investigate the association of socioeconomic status as measured by the average socioeconomic status of the area where a person resides on short-term mortality in adults admitted to an ICU in Queensland, Australia. DESIGN: Secondary data analysis using de-identified data from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation linked to the publicly available area-level Index of Relative Socioeconomic Advantage and Disadvantage from the Australian Bureau of Statistics. SETTING: Adult ICUs from 35 hospitals in Queensland, Australia, from 2006 to 2015. PATIENTS: A total of 218,462 patient admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The outcome measure was inhospital mortality. The main study variable was decile of Index of Relative Socioeconomic Advantage and Disadvantage. The overall crude inhospital mortality was 7.8%; 9% in the most disadvantaged decile and 6.9% in the most advantaged decile (p < 0.001). Increasing socioeconomic disadvantage was associated with increasing severity of illness as measured by Acute Physiology and Chronic Health Evaluation III score, admission with a diagnosis of sepsis or trauma, cardiac, respiratory, renal, and hepatic comorbidities, and remote location. Increasing socioeconomic advantage was associated with elective surgical admission, hematological and oncology comorbidities, and admission to a private hospital (all p < 0.001). After excluding patients admitted after elective surgery, in the remaining 106,843 patients, the inhospital mortality was 13.6%, 13.3% in the most disadvantaged, and 14.1% in the most advantaged. There was no trend in mortality across deciles of socioeconomic status after excluding elective surgery patients. In the logistic regression model adjusting for severity of illness and diagnosis, there was no statistically significant difference in the odds ratio of inhospital mortality for the most disadvantaged decile compared with other deciles. This suggests variables used for risk adjustment may lie on the causal pathway between socioeconomic status and outcome in ICU patients. CONCLUSIONS: Socioeconomic status as defined as Index of Relative Socioeconomic Advantage and Disadvantage of the area in which a patient lives was associated with ICU admission diagnosis, comorbidities, severity of illness, and crude inhospital mortality in this study. Socioeconomic status was not associated with inhospital mortality after excluding elective surgical patients or when adjusted for severity of illness and admission diagnosis. Commonly used measures for risk adjustment in intensive care improve understanding of the pathway between socioeconomic status and outcomes.

Association Between Socioeconomic Status and Outcomes in Critical Care: A Systematic Review and Meta-Analysis

“…A smaller number of studies (n = 10) reported associations between socioeconomic status and ICU length of stay. Six of these demonstrated longer ICU length of stay among patients of lower socioeconomic status (3,7,23,30,35,45), and four found no significant difference (20,39,41,44). Meta-Analysis of ICU Length of Stay.…”

“…Most studies reporting length of stay associations did so for the full cohort (7, 23, 35, 39, 41, 44, 45). Therefore, paradoxically, an early death in ICU may represent a statistically favorable outcome, limiting the utility of these measures.…”

“…Meta-Analysis of ICU Length of Stay. Eight studies met the criteria for meta-analysis of ICU length of stay (6,7,18,31,36,39,44,50). No significant difference in length of stay across socioeconomic groups was noted, with pooled median difference for groups of lowest compared with highest socioeconomic status of -0.11 days (95% CI, -0.29 to 0.06 d) (Fig.…”

Health Equity: A Priority for Critical Illness Survivorship Research

“…Beyond the individual-level, place-level measures, such as those by neighborhood or by city, could prove useful in identifying geographic inequities in critical illness survivorship care and outcomes. One valuable contribution has been the use of regional socioeconomic indexes to quantify an aggregate measure of an area's socioeconomic status (3). These aggregate indices can elucidate general relationships between deprivation and health outcomes, particularly in the absence of individual-level socioeconomic data.…”

“…In contrast, health inequities are the structural or institutional patterns that produce health disparities. In recent studies, critical illness survivors who came from lower socioeconomic backgrounds presented with more severe conditions upon ICU admission (3); had higher in-hospital, 30-day postdischarge, and long-term crude mortality (4); encountered more barriers to a successful ICU discharge (5); and had poorer cognitive and financial outcomes post ICU discharge (6, 7). The common theme among these studies is that there are associations between socioeconomic position and critical illness survivor outcomes, often demonstrating less favorable outcomes in less affluent populations.…”