If anyone has a sense of how socioeconomic status (SES) affects the health of patients, it is Urjeet A. Patel, MD. His head and neck surgery practice is divided between two centers that represent patients from quite different walks of life: Northwestern University Hospital and John H. Stroger, Jr. Hospital of Cook County, both in Chicago. The former is a prestigious university medical center that attracts people from around the globe, whereas the latter is a well-known public hospital that serves as a safety-net facility for uninsured or underinsured patients.
Explore This IssueJune 2008
Seeing patients in different hospital systems gives me good perspective on some of the socioeconomics that affect our patients at Cook County, Dr. Patel told ENT Today. Dr. Patel, Assistant Professor at Northwestern University and Chair of Otolaryngology at Cook County Hospital, is involved in a number of studies looking at patient compliance and health as they relate to socioeconomic issues.
In one study, recently published in Laryngoscope, Dr. Patel and colleagues looked at compliance to radiation therapy in head and neck cancer patients at the Cook County hospital. The study population consisted largely of people who were unemployed, minorities, and presented late with disease. The study found that only 10% of the patients complied fully with radiation treatments, with the remainder missing half or more treatments. However, SES factors such as ethnicity, sex, and primary tumor status did not predict who would be compliant.
Dr. Patel pointed out that the study did not specifically address insurance status, but noted that 40% to 50% of the hospital’s patients are either uninsured or underinsured. He suspects that insurance status may be a big factor in patients not coming in for the treatments they need.
Various studies in the medical literature show that uninsured and underinsured patients tend to present late with disease, have difficulty accessing specialist care, and generally have poorer outcomes than patients with good insurance coverage, he said. That factor alone may be the biggest SES factor with these patients. Dr. Patel plans to look specifically at this and related issues in future studies to help get a better handle on what this means in otolaryngologic cancer patients.
SES factors such as race, education, sex, ethnicity, and income, undeniably have impacts on people’s health too. Race can be linked to genetic risks, or even to perceived or real prejudices; being male or female may increase the risk for certain medical conditions; ethnicity and culture could influence a patient’s attitude toward getting medical care; and low income can be tied in to various barriers to accessing health care, such as not being able to afford to get to medical appointments. Understanding how each of these factors can influence patient health and patterns for accessing care are all important areas to study in otolaryngology, said Dr. Patel.
Insurance Status as Predictor of Health Status
But insurance status may well be the biggest predictor of both individual and population health-making it an important SES area to study.
According to Joel Miller, Senior Vice President for Operations of the National Coalition on Health Care (NCHC), a nonpartisan group that does research on socioeconomics and health care for its 75 member groups and the public, studies show that 47% of Americans delay getting needed medical care because they either lack insurance or cannot afford the out-of-pocket medical costs.
About 90 million people, or one-third of people below age 65, spent all or part of 2006 and 2007 with no health coverage. Yet, Mr. Miller pointed out, Seventy percent of the people in the United States who have no health insurance coverage reside in families that have full-time workers. So the myth that the uninsured are people who are unemployed, slackers, or below the poverty line or are homeless just isn’t true, he said.
The number of employers offering health insurance has plummeted in recent years due to high costs, especially among the small and medium-size employers who can’t afford the premiums.
Studying and learning about SES as it relates to health care is important, not only for better understanding of individual patients, or learning how it affects medical practice, but also for knowing how it affects groups within the population, as well as society as a whole.
When uninsured people present late with disease, their subsequent treatments (for more complex disease) have much higher costs. And the higher costs associated with treating late-presenting patients are spread out across other payers via premiums, Mr. Miller said. Those other payers include the employers who do offer health coverage, as well as individuals. It affects businesses and the general economy in other ways, too.
As overall health care costs rise, corporate operating margins are cut, and companies have less capital for expansion or development, making them less competitive. An Institute of Medicine study showed that $130 billion a year is lost to businesses due to postponed care by uninsured patients, Mr. Miller said. The NCHC is working with various levels of government, medical associations, and other groups to try to develop solutions for these problems.
We are advocating for comprehensive health care reform, Mr. Miller said. All these issues highlight the importance of studying SES in medicine.
Oropharyngeal Cancer and SES
Several studies in the medical literature highlight different SES factors as they affect areas within otolaryngology specifically. A study by researchers at the M. D. Anderson Cancer Center in Houston looked at sociodemographic factors as they related to survival among patients who underwent radiation therapy for squamous cell carcinoma of the oropharynx (SCCOP).
Researchers reviewed the records of all patients (n = 1279) treated for SCCOP at M. D. Anderson between 1987 and 2004. Rates of local recurrence and overall survival were compared with multiple demographic factors. Researchers found that race was strongly associated with recurrence, whereas being uninsured was a significant predictor of worse survival.
Overall, whites did best, Asians and Hispanics did next best, and blacks did worse, said study co-author Sue Yom, MD, now Assistant Professor of Radiation Oncology at the University of California at San Francisco School of Medicine.
The study was undertaken to see whether there were differences between various groups of patients receiving treatment at the center, she said. Care at M. D. Anderson is consistent and very standardized. But even with that level of standardized tertiary care, we found differences in survival between different patient groups, she said. The question was why.
Even as treatment for head and neck cancer has advanced to the point at which patients can be offered a good chance for long-term survival, it is important to know why some patients fail. SES and demographic factors, such as environment, patients’ ability to get themselves to treatment centers, family support, poverty, insurance status, or other factors, can all be reasons for failure.
In this study, it was not a problem with the actual care that was associated with failure. Patients were presenting with more aggressive forms of disease, and had more medical co-morbidities such as diabetes, hypertension or heart disease-factors that can affect how aggressive their cancer treatment can be. Also, many had poor lifestyle habits, such as smoking or alcohol use, and were not seeing primary care physicians who would take care of these issues, Dr. Yom said. This population probably could not afford regular physician visits that would help in managing post-treatment effects and maintaining surveillance for cancer recurrence.
I think we do have a moral obligation to think about whether all our patients have equity of care, Dr. Yom said. Although solutions are not yet at hand, the first step is to identify the problem, she said.
Data from the NCHC also show that visible minorities tend to fare worse, overall, when it comes to health status and outcomes. For instance, life expectancy for African-Americans, on average, is about five years shorter than that of Caucasian-Americans. African-Americans are also more likely to have diabetes, heart disease, and certain cancers than whites, although much of these discrepancies may be caused by genetics and lifestyle. However, minorities are also more likely to be uninsured or underinsured. The NCHC reports that in 2006, almost half of Hispanics did not always go for care when needed, compared with 43% of blacks and 41% of whites.
HNSCC and Race
Yet another study asserts that although race appears to be a predictor of poor survival, the real culprit is insurance status. This study, by Christine Gourin, MD, then at the Medical College of Georgia in Augusta, and colleagues was published in Laryngoscope in 2006. In this study, researchers investigated whether racial disparities exist between black and white patients with head and neck squamous cell carcinoma (HNSCC).
Nationally, blacks constitute 8.8% of HNSCC cases but appear to have a disproportionate burden of disease, with an incidence 47% to 65% higher than among whites. They also have higher rates of disease-specific mortality, tend to develop the disease at a younger age than whites, and present with more advanced-stage disease, the authors wrote. In the medical literature, SES factors had been proposed to explain some of these differences, but a major question related to the fact black patients often have worse survival than whites diagnosed with the same stage of disease.
Researchers looked at data from a hospital tumor registry for all adult HNSCC patients from 1985 to 2002. Various medical, demographic, and SES factors were taken into account and analyzed. A total of 1128 patients were studied, including 430 black patients.
Researchers found that black patients had worse five-year disease-specific survival rates than whites; furthermore, they had a greater incidence of alcohol abuse, higher incidence of advanced stage and inoperable disease at presentation, and were more likely to be treated nonsurgically. They were also more likely to be uninsured and live in areas associated with lower education and income levels than whites.
Although lifestyle and other SES factors seem to play a role, the researchers concluded that the data suggest that racial differences in HNSCC outcomes are primarily related to differences in access to health care.
Rhinosinusitis and SES
In the realm of allergic fungal rhinosinusitis (AFRS), research has shown that various SES factors influence both when patients present with disease, and the treatment they receive. A study of patients in South Carolina was done to investigate whether African-Americans were at higher risk for AFRS.
Researchers wanted to know whether this is a purely racial phenomenon, or were socioeconomic factors, or access to health care, factors related to this, said Rodney Schlosser, MD, Associate Professor and Director of Rhinology and Sinus Surgery in the Department of Otolaryngology-Head and Neck Surgery at the Medical University of South Carolina. There is very little epidemiologic and SES information relating to sinus disease in the medical literature.
Previous studies had already shown that demographics can affect risk, with most cases occurring in the southern and southeastern United States where the climate is warm and mold and fungus counts are high. Other studies had shown factors such as younger age, male gender, and African-American race are also linked to higher risk.
Dr. Schlosser and colleagues reviewed the records of patients who had undergone sinus surgery between 2002 and 2006. Along with information about diagnosis, treatment, insurance status, race, and sex, basic SES and demographic information was determined. Researchers did not have income information for the patients. Instead, the region or county where patients lived was used as a surrogate marker for income status. Information about poverty levels, percentage of African-Americans living in each county, and median household income was derived from data in a Department of Defense database.
We found that the patients with AFRS came from counties that had a higher percentage of residents below the poverty line, lower median income, and a higher percentage of African-Americans, Dr. Schlosser said. About 24% of patients in the study were Medicaid patients or uninsured.
For his own specialty, Dr. Schlosser finds it worth knowing something about how SES may be affecting his patients. It does impact how I treat patients…because you know that they’re probably not going to get as much care when they leave you. And if they’re uninsured, they’re going to have more trouble accessing care or obtaining prescribed medications, he said. Still, there are a number of things not yet known about the pathophysiology and optimal treatment of AFRS, and learning more about patient populations and SES can lead to more answers.
Inequities in Canada
However, insurance status doesn’t explain everything. Looking north to Canada, where there is universal health coverage, there are still disparities evident between people from different socioeconomic groups, according to Keith Denny, PhD, Acting Manager of the Canadian Population Health Initiative (CPHI). He noted that research from Canada and the UK both show that lower-SES populations may have less access to specialty health services as well as primary health care, and are at higher risk of being hospitalized for conditions for which hospitalization may be preventable.
If you’re low income or if you have lower educational attainment, you are much more likely to have poorer health than those with higher income. We don’t know why. There aren’t a lot of studies that really dig away at the mechanisms that link income to health outcomes, or education to health outcomes, he said.
Causes for disparities in health and health care use are complex. It’s entirely plausible that there is no single explanation-that it’s a cluster of different reasons that might change during the course of a person’s life….Income and education might have different roles at different points in people’s lives, Dr. Denny said.
Even factors such as where one lives may have an impact. For instance, a study released by CPHI last year showed that people who live in walkable downtown environments are less likely to be overweight or obese than people who live in suburban neighborhoods, who are more reliant on driving than on walking to their destinations.
If we focus exclusively on health services, we miss a huge part of what it is that’s actually associated with the kinds of things that make people-and groups of people-healthy, he said. Addressing SES-related issues outside the health care system can affect overall health.
Another way to look at the health of a population is to look at international comparisons. According to data from the Organization for Economic Cooperation and Development (OECD) 2007 Fact Book, the average life expectancy at birth in the United States in 2003 for men and women was 77.5 years. In Canada it was 79.9, and was an average of 78.1 for OECD countries. The infant mortality rate was 6.8 deaths per 1000 live births in the United States, compared with 5.3 per 1000 in Canada and an average of 5.7 for OECD countries.
It is important for otolaryngologists to be aware of the extent and type of problems patients face because of SES factors, said Dr. Patel. He pointed out that many public hospitals around the country are being closed. Proving there is a need for them can get necessary, timely help to patients. That, along with finding ways to prevent disease, can reduce the patient burden on the health care system.
Trying to solve it is better than just ignoring a growing problem and sweeping it under the rug. In some way it’s going to come back to impact society, Dr. Patel said.
©2008 The Triological Society