Abstract
Introduction
Lower individual-level socioeconomic status (SES) and area-level SES have each been
associated with poor survival outcomes among patients with multiple myeloma (MM).
A body of literature suggests that individual-level SES may be differentially associated
with mortality depending on area-level SES, and vice versa. This study assessed the
effect of the cross-level interaction between individual low-income status and area
deprivation on mortality among patients with MM.
Materials and Methods
This retrospective cohort study used the Surveillance, Epidemiology, and End Results
(SEER)—Medicare data (2006–2016). Individuals were defined as having low income if
they were dually eligible for Medicare and Medicaid and/or if they received the Low-Income
Subsidy. The county-level Social Deprivation Index (SDI) was linked to individual-level
SEER-Medicare data and categorized into quintiles, from the least deprived (Quintile
1) to the most deprived (Quintile 5). Adjusted hazard ratios (HRs) for the associations
between low-income status, area deprivation, and all-cause mortality were estimated
from a mixed-effects Cox proportional-hazards (PH) model.
Results
The mortality hazard was higher for individuals with low income than individuals without
low income in all quintiles of area deprivation, with the exception of Quintile 5
(Quintile 1: HR 1.53 [95% confidence interval [CI]: 1.32–1.77]; Quintile 2: HR 1.17
[95%CI: 1.01–1.36]; Quintile 3: HR 1.34 [95%CI: 1.18–1.53]; Quintile 4: HR 1.33 [95%CI:
1.17–1.52]; Quintile 5: HR 1.09 [95%CI: 0.96–1.23]). Among individuals without low
income, individuals residing in the most deprived area had a higher mortality hazard
than individuals residing in the least deprived area (HR: 1.22 [95%CI: 1.03–1.45]).
In contrast, among individuals with low income, residing in a more deprived area,
Quintile 2, was associated with a lower hazard of death than residing in the least
deprived area, Quintile 1 (HR: 0.82 [95%CI: 0.67–0.99]), and there was no statistically
significant difference between Quintile 1 and Quintiles 3, 4, and 5.
Discussion
In this analysis, there was a statistically significant cross-level interaction between
individual low-income status and area deprivation on mortality. More research is needed
to fully understand the mechanism behind these associations, but the findings show
that patients and their health should be considered in the context of where they live.
Keywords
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Article info
Publication history
Published online: February 09, 2023
Accepted:
December 6,
2022
Received in revised form:
November 16,
2022
Received:
April 11,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
