Global health researchers agree that the health of a population is determined by its socioeconomic status — especially when it comes to income and education. That said, a surprisingly small portion of the population consumes the majority of a country’s healthcare services. These individuals, therefore, represent a large portion of healthcare spending and are referred to as the “high-cost users” (HCUs) of healthcare, by Dr. Laura Rosella, an assistant professor of epidemiology at the Dalla Lana School of Public Health at U of T.

In an effort to report the relationship between the broader socioeconomic factors — beyond income and education — that determine the presence of HCUs, Rosella recently published a paper in the American Journal of Preventative Medicine, entitled, “Looking Beyond Income and Education.” The study was conducted in collaboration with researchers from the Dalla Lana School of Public Health and other departments at U of T, in addition to those from Public Health Ontario, and St. Michael’s Hospital.

The study analyzed data from the 2003-2004 and 2005-2006 cycles of participants from the Canadian Community Health Survey. The sample looked at 55,734 adults from Ontario following their healthcare consumption for five years, and observed whether or not they became HCUs. Although the probability of a participant becoming an HCU seemed to depend largely upon income and education, the results of the study state that after adjusting for age, “becoming an HCU was most associated with food insecurity.”

When people think about the fiscal end of healthcare sustainability, they overlook the “broader determinants of what brings individuals into the hospital to begin with,” Rosella says, adding, “So a lot of my work focuses on broadening [the] perspective on who uses healthcare — and in this case — who uses a lot of healthcare, so [policymakers] can start addressing some of the root causes of that, and preventing these trajectories before they start.”

Rosella admits that there will always be a gradient of usage; certain people will use the healthcare system more than others, and although this fact may not change it’s important to note who is affected most and why that is the case. Healthcare issues are “disproportionately affecting people that are disadvantaged, and that’s what we need to address because we need to have a sustainable healthcare system, but it needs to be equitable as well,” she says.

“A lot of work to date has been good because it’s making [the healthcare system] more efficient but it’s not really addressing some of the [population’s] health characteristics,” Rosella says. Beyond the commonly studied characteristics of income and education, she found that food-security, housing security, and working conditions are important determinants of healthcare use.

For Rosella, integrating these results into social policy is the next step; “for me, this research is about making the connection between what we do in our social policies, and how it affects all kinds of things, including health,” she says, adding, “ …when we make social policy, it affects everything — not just who’s going to end up on social systems, who’s going to need food banks, but who’s going to use the hospitals disproportionately more than other individuals in the population.”

Going forward, she has two suggestions stemming from her research: “one would be going to policymakers — we have a lot of strategies to address HCUs from a healthcare perspective so I think bringing this information in allows [policymakers] to look for solutions outside the healthcare sector. Second would be, to emphasize the need to measure these things — typically when we design studies in health, we put a lot of detail into the health characteristics that we’re interested in, but maybe not so much into the socioeconomic [characteristics],” she says, adding, “but [socioeconomic characteristics] are so powerful in terms of their determinants of health.”

Rosella also suggests moving from reactive to preventive solutions. “There are a few interventions … that are attempting to coordinate care better for people that are high users and also to offer social solutions to people that are struggling,” she says, adding, “I still think those are reactive solutions and not necessarily preventive.”