DISCUSSION
SECONDARY
We conducted a mixed-methods secondary analysis among individuals enrolled in a randomized controlled trial focused on improving the quality of patient instructions on patient experience. We evaluated the association between low income and post-discharge health outcomes and explored patient and caregiver perspectives on the role of income disparities and costs following discharge from hospital. Our study found few quantitative differences between the post-discharge health outcomes of individuals with low income when compared to individuals with higher income. Our qualitative results however highlight numerous costs that exist for patients and their families following a care transition to home which may not have been identified quantitatively based on income category alone. First, transportation costs, out-of-pocket medication, medical equipment, and unreliable home care services were cited barriers to recovery. Furthermore, caregivers incurred social costs and lost wages due to their caregiving responsibilities. Our study findings also highlighted three main adaptation strategies which was reported with slightly higher frequency among our low income and unknown income categories (budgeting, receiving caregiver support, and seeking private services) which may help explain how patients and caregivers offset constraints in a publicly funded system.This study has notable limitations. First, this study took place among a selective group of patients with medical and orthopedic conditions receiving healthcare and public services across one province in Canada (Ontario) with the majority of participants residing in the city of Toronto. As health care and services are delivered at a provincial level, identified challenges and limitations may vary in other areas of Canada. Second, individuals were enrolled from an RCT which explored the impact of a written discharge summary with patient-oriented instructions on patient experience. While the intervention was equally provided to individuals from all income classes and did not find differences to patient experience nor adherence to follow-up appointments and further healthcare use, it is certainly possible healthcare-seeking differences may have not been captured and led to selection bias in our study. Third, the qualitative component of the mixed-methods study is designed to explore rather than to test a hypothesis, and further studies are warranted to clarify if those with caregivers or additional private support may differ from individuals without these supports. Lastly, 24% of those who were interviewed were in the high income household category, which may have underestimated the true costs and impact of these costs on individuals with low SES. Our focus on costs beyond solely SES and wide range of words captured in our interviews is a strength of our study. While themes identified are similar to other studies, further research with a larger sample among individuals with self-reported low income or other measures of financial instability in a public-payer system such as Canada’s is needed.There are several potential explanations why we did not find an association between income and the studied patient outcomes. It is possible that low-income individuals in our study had different health-seeking behaviors which were not captured in our study. Recent efforts in Ontario have worked to ensure new care interventions and models of care support patient and caregiver engagement and higher quality communication at time of discharge.Our findings add to the current literature by sharing important insights on how patients and caregivers may adapt by prioritizing finances and relying on their support networks when transitioning from hospital to home. These findings are important, as little attention up to now has been given to the costs to patients and their families during care transitions in a public-payer system such as Canada. The financial and social burden that caregivers experience is an important area for further research and intervention particularly given what is known around the essential role of caregivers in the post-discharge period.