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"Bring the hoses to where the fire is!": differential impacts of marginalization and socioeconomic status on COVID-19 case counts and healthcare costs

Cheung DC, Bremner KE, Tsui TCO, Croxford R, Lapointe-Shaw L, Del Giudice L, Mendlowitz A, Perlis N, Pataky RE, Teckle P, Zeitouny S, Wong WWL, Sander B, Peacock S, Krahn MD, Kulkarni GS, Mulder C. Value Health. 2022; 25(8):1307-16. Epub 2022 May 5. DOI:

Objectives — Local health leaders and the Director General of the World Health Organization alike have observed that COVID-19 “does not discriminate.” Nevertheless, the disproportionate representation of people of low socioeconomic status among those infected resembles discrimination. This population-based retrospective cohort study examined COVID-19 case counts and publicly funded healthcare costs in Ontario, Canada, with a focus on marginalization.

Methods — Individuals with their first positive severe acute respiratory syndrome coronavirus 2 test from January 1, 2020 to June 30, 2020, were linked to administrative databases and matched to negative/untested controls. Mean net (COVID-19–attributable) costs were estimated for 30 days before and after diagnosis, and differences among strata of age, sex, comorbidity, and measures of marginalization were assessed using analysis of variance tests.

Results — We included 28 893 COVID-19 cases (mean age 54 years, 56% female). Most cases remained in the community (20 545, 71.1%) or in long-term care facilities (4478, 15.5%), whereas 944 (3.3%) and 2926 (10.1%) were hospitalized, with and without intensive care unit, respectively.

Case counts were skewed across marginalization strata with 2 to 7 times more cases in neighborhoods with low income, high material deprivation, and highest ethnic concentration.

Mean net costs after diagnosis were higher for males ($4752 vs $2520 for females) and for cases with higher comorbidity ($1394-$7751) (both P < .001) but were similar across levels of most marginalization dimensions (range $3232-$3737, all P ≥ .19).

Conclusions — This study suggests that allocating resources unequally to marginalized individuals may improve equality in outcomes. It highlights the importance of reducing risk of COVID-19 infection among marginalized individuals to reduce overall costs and increase system capacity.

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