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Satokangas M, Arffman M, Agerholm J, Thielen K, Hougaard CØ, Andersen I, Burström B, Keskimäki I. Performing up to Nordic principles? Geographic and socioeconomic equity in ambulatory care sensitive conditions among older adults in capital areas of Denmark, Finland and Sweden in 2000-2015. BMC Health Serv Res 2023; 23:835. [PMID: 37550672 PMCID: PMC10405465 DOI: 10.1186/s12913-023-09855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 07/27/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance. METHODS We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities. RESULTS Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment. CONCLUSIONS While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.
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Affiliation(s)
- Markku Satokangas
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.
- Network of Academic Health Centres and Department of General Practice and Primary Health Care, University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland.
| | - Martti Arffman
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | - Janne Agerholm
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Karsten Thielen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Ørsted Hougaard
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ingelise Andersen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bo Burström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ilmo Keskimäki
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
- Faculty of Social Sciences, Tampere University, 33014, Tampere, Finland
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McMinn MA, Seaman R, Dundas R, Pell JP, Leyland AH. Socio-economic inequalities in rates of amenable mortality in Scotland: Analyses of the fundamental causes using the Scottish Longitudinal Study, 1991-2010. POPULATION, SPACE AND PLACE 2022; 28:psp.2385. [PMID: 35411206 PMCID: PMC7612592 DOI: 10.1002/psp.2385] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/02/2020] [Indexed: 05/29/2023]
Abstract
Socio-economic inequalities in amenable mortality rates are increasing across Europe, which is an affront to universal healthcare systems where the numbers of, and inequalities in, amenable deaths should be minimal and declining over time. However, the fundamental causes theory proposes that inequalities in health will be largest across preventable causes, where unequally distributed resources can be used to gain an advantage. Information on individual-level inequalities that may better reflect the fundamental causes remains limited. We used the Scottish Longitudinal Study, with follow-up to 2010 to examine trends in amenable mortality by a range of socioeconomic position measures. Large inequalities were found for all measures of socioeconomic position and were lowest for educational attainment, higher for social class and highest for social connection. To reduce inequalities, amenable mortality needs to be interpreted both as an indicator of healthcare quality and as a reflection of the unequal distribution of socio-economic resources.
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Affiliation(s)
- Megan A. McMinn
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
- Usher Institute, University of Edinburgh, Edinburgh,UK
| | - Rosie Seaman
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Ruth Dundas
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Jill P. Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alastair H. Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Kaihlanen AM, Virtanen L, Buchert U, Safarov N, Valkonen P, Hietapakka L, Hörhammer I, Kujala S, Kouvonen A, Heponiemi T. Towards digital health equity - a qualitative study of the challenges experienced by vulnerable groups in using digital health services in the COVID-19 era. BMC Health Serv Res 2022; 22:188. [PMID: 35151302 PMCID: PMC8840681 DOI: 10.1186/s12913-022-07584-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/25/2022] [Indexed: 12/03/2022] Open
Abstract
Background The COVID-19 pandemic has given an unprecedented boost to already increased digital health services, which can place many vulnerable groups at risk of digital exclusion. To improve the likelihood of achieving digital health equity, it is necessary to identify and address the elements that may prevent vulnerable groups from benefiting from digital health services. This study examined the challenges experienced by vulnerable groups in using digital health services during the COVID-19 pandemic. Methods Qualitative descriptive design was utilized. Semi-structured interviews were conducted between October 2020 and May 2021. The participants (N = 74) were older adults, migrants, mental health service users, high users of health services, and the unemployed. Qualitative content analysis with both inductive and deductive approach was used to analyze the data. Challenges related to the use of digital health services were interpreted through digital determinants of health from the Digital Health Equity Framework. Results For most of the participants the access to digital health services was hampered by insufficient digital, and / or local language skills. The lack of support and training, poor health, as well as the lack of strong e-identification or suitable devices also prevented the access. Digital services were not perceived to be applicable for all situations or capable of replacing face-to-face services due to the poor communication in the digital environment. Fears and the lack of trust regarding digital platforms were expressed as well as concerns related to the security of the services. Contact with a health care professional was also considered less personal and more prone to misunderstandings in the digital environment than in face-to-face services. Finally, digital alternatives were not always available as desired by participants, or participants were unaware of existing digital services and their value. Conclusion Several development needs in the implementation of digital health services were identified that could improve equal access to and benefits gained from digital services in the future. While digital health services are increasing, traditional face-to-face services will still need to be offered alongside the digital ones to ensure equal access to services. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07584-4.
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Raittio E, Huumonen S, Suominen AL. Is the technical quality of root fillings associated with socioeconomic status? A cross-sectional study among Finnish adults. Eur J Oral Sci 2020; 128:415-422. [PMID: 32776471 DOI: 10.1111/eos.12730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
Abstract
We investigated differences in the technical quality of root fillings according to socioeconomic status. In the Finnish Health 2000 Survey, which comprised a sample of 8,028 adults aged over 29 yr, 6,115 underwent panoramic radiography. A total of 7,986 endodontically treated teeth were detected among 3,095 participants. The criterion for a technically inadequate root filling was a distance from the root filling to the root apex of over 3 mm or a filling extruding beyond the apex. Educational level, employment status, and income were the measures of socioeconomic status. Differences in the frequency of inadequate root fillings according to socioeconomic status were investigated using a multilevel logistic mixed-effects model taking into account age, gender, number of teeth, and type of root filled tooth. Almost half (46%) of the root fillings were inadequate. Among the over 64-yr-olds, higher education and higher income were associated with a higher probability of having an inadequate root filling. Among the under 65-yr-olds, socioeconomic status was not associated with root filling quality. Contrary to expectation, lower socioeconomic status was not associated with poorer endodontic treatment quality; however, higher income and higher education was associated with higher odds for inadequate root fillings among the over 64-yr-olds.
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Affiliation(s)
- Eero Raittio
- Institute of Dentistry, University of Eastern Finland, Kuopio, Finland
| | - Sisko Huumonen
- Institute of Dentistry, University of Eastern Finland, Kuopio, Finland.,Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland.,Research Unit of Oral Health Sciences, University of Oulu, Oulu, Finland
| | - Anna L Suominen
- Institute of Dentistry, University of Eastern Finland, Kuopio, Finland.,Department of Oral and Maxillofacial Diseases, Kuopio University Hospital, Kuopio, Finland.,Public Health Evaluation and Projection Unit, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
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Lumme S, Manderbacka K, Karvonen S, Keskimäki I. Trends of socioeconomic equality in mortality amenable to healthcare and health policy in 1992-2013 in Finland: a population-based register study. BMJ Open 2018; 8:e023680. [PMID: 30567823 PMCID: PMC6303580 DOI: 10.1136/bmjopen-2018-023680] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/05/2018] [Accepted: 11/20/2018] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To study trends in socioeconomic equality in mortality amenable to healthcare and health policy interventions. DESIGN A population-based register study. SETTING Nationwide data on mortality from the Causes of Death statistics for the years 1992-2013. PARTICIPANTS All deaths of Finnish inhabitants aged 25-74. OUTCOME MEASURES Yearly age-standardised rates of mortality amenable to healthcare interventions, alcohol-related mortality, ischaemic heart disease mortality and mortality due to all the other causes by income. Concentration index (C) was used to evaluate the magnitude and changes in income group differences. RESULTS Significant socioeconomic inequalities favouring the better-off were observed in each mortality category among younger (25-64) and older (65-74) age groups. Inequality was highest in alcohol-related mortality, C was -0.58 (95% CI -0.62 to -0.54) among younger men in 2008 and -0.62 (-0.72 to -0.53) among younger women in 2013. Socioeconomic inequality increased significantly during the study period except for alcohol-related mortality among older women. CONCLUSIONS The increase in socioeconomic inequality in mortality amenable to healthcare and health policy interventions between 1992 and 2013 suggests that either the means or the implementation of the health policies have been inadequate.
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Affiliation(s)
- Sonja Lumme
- Social and Health Systems Research Unit, Department of Health and Social Care Systems, National Institute for Health and Welfare, Helsinki, Finland
| | - Kristiina Manderbacka
- Social and Health Systems Research Unit, Department of Health and Social Care Systems, National Institute for Health and Welfare, Helsinki, Finland
| | - Sakari Karvonen
- Social Policy Research Unit, Department of Health and Social Care Systems, National Institute for Health and Welfare, Helsinki, Finland
| | - Ilmo Keskimäki
- Social and Health Systems Research Unit, Department of Health and Social Care Systems, National Institute for Health and Welfare, Helsinki, Finland
- University of Tampere, Faculty of Social Sciences, Tampere, Finland
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Nolasco A, Pereyra-Zamora P, Sanchis-Matea E, Tamayo-Fonseca N, Caballero P, Melchor I, Moncho J. Economic Crisis and Amenable Mortality in Spain. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2298. [PMID: 30347682 PMCID: PMC6211017 DOI: 10.3390/ijerph15102298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/09/2018] [Accepted: 10/16/2018] [Indexed: 12/24/2022]
Abstract
Background: Both overall mortality and avoidable mortality have decreased in recent years in most European countries. It has become clear that less privileged socioeconomic groups have an increased risk of death. In 2008, most countries went into a severe economic recession, whose effects on the health of the population are still ongoing. While on the one hand, some evidence associates the economic crisis with positive health outcomes (pro-cyclical effect), on the other hand, some other evidence suggests that the economic crisis may pose serious public health problems (counter-cyclical effect), which has given rise to controversy. Objectives: To describe the evolution of overall mortality and amenable mortality in Spain between 2002⁻2007 (before the economic crisis) and 2008⁻2013 (during the economic crisis), nationally and by province, as well as to analyse trends in the risks of death and their association with indicators of the impact of the crisis. Methods: Ecological study of overall mortality and amenable mortality describing the evolution of the risks of death between 2002⁻2007 and 2008⁻2013. Age Standardised Rates were calculated, as well as their percentage change between periods. The association between percentage changes and provincial indicators of the impact of the crisis was analysed. Amenable mortality was studied both overall and categorised into five groups. Results: Amenable mortality represented 8.25% of overall mortality in 2002⁻2007, and 6.93% in 2008⁻2013. Age Standardised Rates for overall mortality and global amenable mortality generally declined, with the sharpest decline in amenable mortality. Decreases in overall mortality and amenable mortality were directly related to vulnerability indicators. The most significant decreases were registered in ischaemic heart disease, cerebrovascular disease, and other amenable causes. The relationship with vulnerability indices varied from direct (cancer) to inverse (hypertensive disease). Conclusions: Amenable mortality shows a more significant decrease than overall mortality between both study periods, albeit unevenly between provinces causes of death. Higher vulnerability indicators entail greater declines, although this trend varied for different causes. Mortality trends and their relationship with socioeconomic indicators in a situation of crisis must be conducted cautiously, taking into consideration a possible pro-cyclical effect.
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Affiliation(s)
- Andreu Nolasco
- Research Unit for the Analysis of Mortality and Health Statistics, Department of Community Nursing, Preventive Medicine, Public Health and History of Science, University of Alicante, Campus de San Vicente del Raspeig s/n, Ap. 99-03080 Alicante, Spain.
| | - Pamela Pereyra-Zamora
- Research Unit for the Analysis of Mortality and Health Statistics, Department of Community Nursing, Preventive Medicine, Public Health and History of Science, University of Alicante, Campus de San Vicente del Raspeig s/n, Ap. 99-03080 Alicante, Spain.
| | - Elvira Sanchis-Matea
- Research Unit for the Analysis of Mortality and Health Statistics, Department of Community Nursing, Preventive Medicine, Public Health and History of Science, University of Alicante, Campus de San Vicente del Raspeig s/n, Ap. 99-03080 Alicante, Spain.
| | - Nayara Tamayo-Fonseca
- Research Unit for the Analysis of Mortality and Health Statistics, Department of Community Nursing, Preventive Medicine, Public Health and History of Science, University of Alicante, Campus de San Vicente del Raspeig s/n, Ap. 99-03080 Alicante, Spain.
| | - Pablo Caballero
- Research Unit for the Analysis of Mortality and Health Statistics, Department of Community Nursing, Preventive Medicine, Public Health and History of Science, University of Alicante, Campus de San Vicente del Raspeig s/n, Ap. 99-03080 Alicante, Spain.
| | - Inmaculada Melchor
- Research Unit for the Analysis of Mortality and Health Statistics, Department of Community Nursing, Preventive Medicine, Public Health and History of Science, University of Alicante, Campus de San Vicente del Raspeig s/n, Ap. 99-03080 Alicante, Spain.
- Mortality Register of the Valencian Community, section of Epidemiological Studies and Health Statistics, General Sub-directorate of Epidemiology and Health Monitoring, General Directorate of Public Health, Health Ministry of the Valencian Government, 03010 Alicante, Spain.
| | - Joaquín Moncho
- Research Unit for the Analysis of Mortality and Health Statistics, Department of Community Nursing, Preventive Medicine, Public Health and History of Science, University of Alicante, Campus de San Vicente del Raspeig s/n, Ap. 99-03080 Alicante, Spain.
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Mackenbach JP, Hu Y, Artnik B, Bopp M, Costa G, Kalediene R, Martikainen P, Menvielle G, Strand BH, Wojtyniak B, Nusselder WJ. Trends In Inequalities In Mortality Amenable To Health Care In 17 European Countries. Health Aff (Millwood) 2018; 36:1110-1118. [PMID: 28583971 DOI: 10.1377/hlthaff.2016.1674] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Little is known about the effectiveness of health care in reducing inequalities in health. We assessed trends in inequalities in mortality from conditions amenable to health care in seventeen European countries in the period 1980-2010 and used models that included country fixed effects to study the determinants of these trends. Our findings show remarkable declines over the study period in amenable mortality among people with a low level of education. We also found stable absolute inequalities in amenable mortality over time between people with low and high levels of education, but widening relative inequalities. Higher health care expenditure was associated with lower mortality from amenable causes, but not from nonamenable causes. The effect of health care expenditure on amenable mortality was equally strong, in relative terms, among people with low levels of education and those with high levels. As a result, higher health care expenditure was associated with a narrowing of absolute inequalities in amenable mortality. Our findings suggest that in the European context, more generous health care funding provides some protection against inequalities in amenable mortality.
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Affiliation(s)
- Johan P Mackenbach
- Johan P. Mackenbach is a professor of public health and chair of the Department of Public Health, Erasmus University Medical Center, in Rotterdam, the Netherlands
| | - Yannan Hu
- Yannan Hu is a postdoctoral fellow in the Department of Public Health, Erasmus University Medical Center
| | - Barbara Artnik
- Barbara Artnik is on the Faculty of Medicine, Department of Public Health, University of Ljubljana, in Slovenia
| | - Matthias Bopp
- Matthias Bopp is a senior researcher at the Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, in Switzerland
| | - Giuseppe Costa
- Giuseppe Costa is a professor of public health at the Turin University Medical School and chair of the San Luigi Hospital Epidemiology Unit and of the Azienda Sanitaria Locale (Regional Epidemiology Unit) in Turin, Italy
| | - Ramune Kalediene
- Ramune Kalediene is dean of the Faculty of Public Health and head of the Department of Health Management at Lithuanian University of Health Sciences, in Kaunas
| | - Pekka Martikainen
- Pekka Martikainen is a professor of demography in the Department of Sociology, University of Helsinki, in Finland
| | - Gwenn Menvielle
- Gwenn Menvielle is a senior researcher at the Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Institut Nationale de la Santé et de la Recherche Médicale, in Villejuif, France
| | - Bjørn H Strand
- Bjørn H. Strand is a senior researcher in the Division of Epidemiology, Norwegian Institute of Public Health, in Oslo
| | - Bogdan Wojtyniak
- Bogdan Wojtyniak is head of the Department of Monitoring and Analyses of Population Health, National Institute of Public Health-National Institute of Hygiene, in Warsaw, Poland
| | - Wilma J Nusselder
- Wilma J. Nusselder is an assistant professor in the Department of Public Health, Erasmus University Medical Center
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Weber A, Clerc M. Deaths amenable to health care: Converging trends in the EU? Health Policy 2017; 121:644-652. [PMID: 28456413 DOI: 10.1016/j.healthpol.2017.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 10/19/2022]
Abstract
Amenable mortality has been recently included in the joint monitoring tool by the European Commission and Member States to assess a country's health system performance. Amenable deaths are premature deaths, which should not have occurred at this stage in the light of timely and effective health care. This paper recalculated annual amenable mortality rates for 28EU countries and the EU for the period 1994-2013 based on the recently published list of deaths amenable to health care by Eurostat. Thereby, it offers a consistent calculation of amenable mortality across European Member States and provides time series data on amenable mortality. In addition, a sensitivity analysis of the amenable mortality indicator for varying age limits and attributional weights of circulatory system diseases is carried out. While large improvements were made in reducing amenable deaths in all European countries, great variations persist among Member States. Most of the decreases in amenable mortality are explained by a substantial reduction of deaths due to circulatory system diseases. In addition, even in countries with good national performance on amenable mortality, sub-national analysis shows that great regional disparities exist. The sensitivity analysis revealed that for the large majority of countries results are stable across different attributional weights used for ischaemic heart diseases and cerebrovascular diseases.
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Affiliation(s)
- Anke Weber
- Hamm-Lippstadt University of Applied Sciences, Department 2, Marker Allee 76-78, 59063 Hamm, Germany.
| | - Marie Clerc
- Eurostat, Health Administrative Data, Luxembourg.
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Virtanen M, Lallukka T, Ervasti J, Rahkonen O, Lahelma E, Pentti J, Pietiläinen O, Vahtera J, Kivimäki M. The joint contribution of cardiovascular disease and socioeconomic status to disability retirement: A register linkage study. Int J Cardiol 2016; 230:222-227. [PMID: 28063665 DOI: 10.1016/j.ijcard.2016.12.166] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/23/2016] [Accepted: 12/25/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Whether low occupational class amplifies the risk of disability retirement among employees with cardiovascular disease (CVD) is unknown. We examined this issue in two prospective cohort studies. METHODS In the Finnish Public Sector Study and the Helsinki Health Study (n=50.799 employees), prevalent CVD (coronary heart disease or stroke, n=1269) was ascertained using records from national health registers, self-reported doctor-diagnosed diseases, and Rose Angina Questionnaire. Data linkage to national pension registers allowed the follow up of disability retirement among the participants for a mean of six years. We analysed the associations of occupational class and CVD with disability retirement using Cox regression, tested interactions between occupational class and prevalent CVD in predicting disability retirement by calculating the Synergy Index, and pooled the results from the two studies using fixed-effect meta-analysis. RESULTS Compared with the participants from high occupational class and no CVD, the participants from the low occupational class without CVD had a 2.13-fold (95% CI 1.97-2.30), those with high occupational class and CVD a 2.18-fold (1.73-2.74); and those with both low occupational class and CVD a 4.49-fold (3.83-5.26) risk of disability retirement. A Synergy Index of 1.55 (1.16-2.06) suggested a greater than additive effect for low occupational class and CVD in combination. CONCLUSIONS Individuals with both low occupational class and CVD are at a particularly high risk of premature exit from the labour market due to work disability. These findings suggest that better preventive strategies are needed to improve prognosis in this risk group.
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Affiliation(s)
| | - Tea Lallukka
- Finnish Institute of Occupational Health, Helsinki, Finland; Department of Public Health, University of Helsinki, Finland
| | - Jenni Ervasti
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Ossi Rahkonen
- Department of Public Health, University of Helsinki, Finland
| | - Eero Lahelma
- Department of Public Health, University of Helsinki, Finland
| | - Jaana Pentti
- Finnish Institute of Occupational Health, Turku, Finland
| | | | - Jussi Vahtera
- Department of Public Health, University of Turku, Turku, Finland; Turku University Hospital, Turku, Finland
| | - Mika Kivimäki
- Finnish Institute of Occupational Health, Helsinki, Finland; Department of Public Health, University of Helsinki, Finland; Department of Epidemiology and Public Health, University College London, London, UK
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Chen BK, Yang YT, Yang CY. Trends in amenable deaths based on township income quartiles in Taiwan, 1971-2008: did universal health insurance close the gap? J Public Health (Oxf) 2016; 38:e524-e536. [PMID: 28158683 DOI: 10.1093/pubmed/fdv156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brian K Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street Suite 354, Columbia, SC 29208, USA
| | - Y Tony Yang
- College of Health and Human Services, George Mason University, 4400 University Dr, Fairfax, VA 22030-4444, USA
| | - Chun-Yuh Yang
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan
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Cookson R, Asaria M, Ali S, Ferguson B, Fleetcroft R, Goddard M, Goldblatt P, Laudicella M, Raine R. Health Equity Indicators for the English NHS: a longitudinal whole-population study at the small-area level. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04260] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundInequalities in health-care access and outcomes raise concerns about quality of care and justice, and the NHS has a statutory duty to consider reducing them.ObjectivesThe objectives were to (1) develop indicators of socioeconomic inequality in health-care access and outcomes at different stages of the patient pathway; (2) develop methods for monitoring local NHS equity performance in tackling socioeconomic health-care inequalities; (3) track the evolution of socioeconomic health-care inequalities in the 2000s; and (4) develop ‘equity dashboards’ for communicating equity findings to decision-makers in a clear and concise format.DesignLongitudinal whole-population study at the small-area level.SettingEngland from 2001/2 to 2011/12.ParticipantsA total of 32,482 small-area neighbourhoods (lower-layer super output areas) of approximately 1500 people.Main outcome measuresSlope index of inequality gaps between the most and least deprived neighbourhoods in England, adjusted for need or risk, for (1) patients per family doctor, (2) primary care quality, (3) inpatient hospital waiting time, (4) emergency hospitalisation for chronic ambulatory care-sensitive conditions, (5) repeat emergency hospitalisation in the same year, (6) dying in hospital, (7) mortality amenable to health care and (8) overall mortality.Data sourcesPractice-level workforce data from the general practice census (indicator 1), practice-level Quality and Outcomes Framework data (indicator 2), inpatient hospital data from Hospital Episode Statistics (indicators 3–6) and mortality data from the Office for National Statistics (indicators 6–8).ResultsBetween 2004/5 and 2011/12, more deprived neighbourhoods gained larger absolute improvements on all indicators except waiting time, repeat hospitalisation and dying in hospital. In 2011/12, there was little measurable inequality in primary care supply and quality, but inequality was associated with 171,119 preventable hospitalisations and 41,123 deaths amenable to health care. In 2011/12, > 20% of Clinical Commissioning Groups performed statistically significantly better or worse than the England equity benchmark.LimitationsGeneral practitioner supply is a limited measure of primary care access, need in deprived neighbourhoods may be underestimated because of a lack of data on multimorbidity, and the quality and outcomes indicators capture only one aspect of primary care quality. Health-care outcomes are adjusted for age and sex but not for other risk factors that contribute to unequal health-care outcomes and may be outside the control of the NHS, so they overestimate the extent of inequality for which the NHS can reasonably be held responsible.ConclusionsNHS actions can have a measurable impact on socioeconomic inequality in both health-care access and outcomes. Reducing inequality in health-care outcomes is more challenging than reducing inequality of access to health care. Local health-care equity monitoring against a national benchmark can be performed using any administrative geography comprising ≥ 100,000 people.Future workExploration of quality improvement lessons from local areas performing well and badly on health-care equity, improved methods including better measures of need and risk and measures of health-care inequality over the life-course, and monitoring of other dimensions of equity. These indicators can also be used to evaluate the health-care equity impacts of interventions and make international health-care equity comparisons.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Miqdad Asaria
- Centre for Health Economics, University of York, York, UK
| | - Shehzad Ali
- Centre for Health Economics, University of York, York, UK
- Department of Health Sciences, University of York, York, UK
| | - Brian Ferguson
- Knowledge and Intelligence, Public Health England, York, UK
| | | | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Peter Goldblatt
- Institute of Health Equity, University College London, London, UK
| | | | - Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
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Strømme EM, Norheim OF. Global Health Inequality: Comparing Inequality-Adjusted Life Expectancy over Time. Public Health Ethics 2016. [DOI: 10.1093/phe/phw033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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13
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Lehikoinen M, Arffman M, Manderbacka K, Elovainio M, Keskimäki I. Comparative observational study of mortality amenable by health policy and care between rural and urban Finland: no excess segregation of mortality in the capital despite its increasing residential differentiation. Int J Equity Health 2016; 15:59. [PMID: 27044484 PMCID: PMC4820906 DOI: 10.1186/s12939-016-0348-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 04/01/2016] [Indexed: 11/10/2022] Open
Abstract
Background Large cities are often claimed to display more distinct geographical and socioeconomic health inequalities than other areas due to increasing residential differentiation. Our aim was to assess whether geographical inequalities in mortality within the capital (City of Helsinki) both exceeded that in other types of geographical areas in Finland, and whether those differences were dependent on socioeconomic inequalities. Methods We analysed the inequality of distribution separately for overall, ischemic heart disease and alcohol-related mortality, and mortality amenable (AM) to health care interventions in 1992–2008 in three types of geographical areas in Finland: City of Helsinki, other large cities, and small towns and rural areas. Mortality data were acquired as secondary data from the Causes of Death statistics from Statistics Finland. The assessment of changing geographical differences over time, that is geographical inequalities, was performed using Gini coefficients. As some of these differences might arise from socioeconomic factors, we assessed socioeconomic differences with concentration indices in parallel to an analysis of geographical differences. To conclude the analysis, we compared the changes over time of these inequalities between the three geographical areas. Results While mortality rates mainly decreased, alcohol-related mortality in the lowest income quintile increased. Statistically significant differences over time were found in all mortality groups, varying between geographical areas. Socioeconomic differences existed in all mortality groups and geographical areas. In the study period, geographical differences in mortality remained relatively stable but income differences increased substantially. For instance, the values of concentration indices for AM changed by 54 % in men (p < 0.027) and by 62 % in women (p < 0.016). Only slight differences existed in the time trends of Gini or in the concentration indices between the geographical areas. Conclusions No geographical or income-related differences in the distribution of mortality existed between Helsinki and other urban or rural areas of Finland. This suggests that the effect of increasing residential differentiation in the capital may have been mitigated by the policies of positive discrimination and social mixing. One of the main reasons for the increase in health inequalities was growth of alcohol-related mortality, especially among those with the lowest incomes.
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Affiliation(s)
- Markku Lehikoinen
- Department of Social Services and Health Care, City of Helsinki, P.O. Box 6100, 00099, Helsinki, Finland. .,Network of Academic Health Centres and Department of General Practice and Primary Health Care, University of Helsinki, P.O. Box 20 , Tukholmankatu 8 B, 00014, Helsinki, Finland.
| | - Martti Arffman
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland
| | - Kristiina Manderbacka
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland
| | - Marko Elovainio
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland.,Institute of Behavioural Sciences, University of Helsinki, P.O. Box 9, 00014, Helsinki, Finland
| | - Ilmo Keskimäki
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland.,School of Health Sciences, University of Tampere, 33014, Tampere, Finland
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14
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Income related inequalities in avoidable mortality in Norway: A population-based study using data from 1994–2011. Health Policy 2015; 119:889-98. [DOI: 10.1016/j.healthpol.2015.04.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 01/13/2015] [Accepted: 04/27/2015] [Indexed: 11/23/2022]
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15
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Manderbacka K, Jutta J, Martti A, Hanna R, Unto H, Ilmo K. National and regional trends in equity within specialised health care in Finland in 2002-2010. Scand J Public Health 2015; 43:514-7. [PMID: 25953954 DOI: 10.1177/1403494815585615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 11/17/2022]
Abstract
AIMS Equity is an important goal of health-care systems. Nevertheless, previous research indicates that health-care systems do not deliver health services equitably and that socio-economic differences in both health and health-care use may even be increasing. The aim of this study was to investigate national and regional time trends in equity within specialised health care in Finland. METHODS The data used in the study were obtained from the Hospital Discharge Register covering all hospital admissions in Finland from 2002 to 2010 for patients having utilised specialised non-psychiatric inpatient care. Income data were individually linked to these register data. Equity was measured in terms of concentration index at hospital district level. RESULTS Concentration indices across hospital districts and years were negative, suggesting specialised inpatient care to be distributed pro poor. Overall, the concentration indices remained fairly stable during the study period. However, a drop in the indices appeared in all hospital districts between 2005 and 2008, and a reverse development was found after 2008. In internal medicine departments of the hospital districts, the distribution of the indices was more pro poor compared to surgery but the trends within both specialties were similar to those within specialised care in general. CONCLUSIONS The pro-poor distribution of concentration indices is consistent with morbidity differences the introduction of the waiting time guarantee in 2005, which brought along an increment in resources, as well as the launch of new regulations and financial incentives, probably increased access to specialised health care among low-income patients temporarily.
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Affiliation(s)
- Kristiina Manderbacka
- Health and Social Systems Research Unit, National Institute for Health and Welfare, Finland
| | - Järvelin Jutta
- CHESS, National Institute for Health and Welfare, Finland
| | - Arffman Martti
- Health and Social Systems Research Unit, National Institute for Health and Welfare, Finland
| | - Rättö Hanna
- Helsinki and Uusimaa Hospital District, Finland
| | - Häkkinen Unto
- CHESS, National Institute for Health and Welfare, Finland
| | - Keskimäki Ilmo
- Health and Social Systems Research Unit, National Institute for Health and Welfare, Finland School of Health Sciences, University of Tampere, Finland
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16
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Nolasco A, Moncho J, Quesada JA, Melchor I, Pereyra-Zamora P, Tamayo-Fonseca N, Martínez-Beneito MA, Zurriaga O, Ballesta M, Daponte A, Gandarillas A, Domínguez-Berjón MF, Marí-Dell'Olmo M, Gotsens M, Izco N, Moreno MC, Sáez M, Martos C, Sánchez-Villegas P, Borrell C. Trends in socioeconomic inequalities in preventable mortality in urban areas of 33 Spanish cities, 1996-2007 (MEDEA project). Int J Equity Health 2015; 14:33. [PMID: 25879739 PMCID: PMC4392789 DOI: 10.1186/s12939-015-0164-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/17/2015] [Indexed: 11/30/2022] Open
Abstract
Background Preventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996–2001 and 2002–2007. Methods We analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used. Results Preventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996–2001 and 10.9 in 2002–2007), though not so clearly among women (3.3% in 1996–2001 and 2.9% in 2002–2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities. Conclusions Preventable mortality decreased between the 1996–2001 and 2002–2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process.
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Affiliation(s)
- Andreu Nolasco
- Unidad de Investigación de Análisis de la Mortalidad y Estadísticas Sanitarias. Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia. Campus de San Vicente del Raspeig s/n. Apartado 99, Universidad de Alicante, 03080, Alicante, España.
| | - Joaquin Moncho
- Unidad de Investigación de Análisis de la Mortalidad y Estadísticas Sanitarias. Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia. Campus de San Vicente del Raspeig s/n. Apartado 99, Universidad de Alicante, 03080, Alicante, España.
| | - Jose Antonio Quesada
- Unidad de Investigación de Análisis de la Mortalidad y Estadísticas Sanitarias. Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia. Campus de San Vicente del Raspeig s/n. Apartado 99, Universidad de Alicante, 03080, Alicante, España.
| | - Inmaculada Melchor
- Unidad de Investigación de Análisis de la Mortalidad y Estadísticas Sanitarias. Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia. Campus de San Vicente del Raspeig s/n. Apartado 99, Universidad de Alicante, 03080, Alicante, España. .,Registro de Mortalidad de la Comunidad Valenciana, Servicio de Estudios Epidemiológicos y Estadísticas Sanitarias, Subdirección General de Epidemiología y Vigilancia de la Salud. Conselleria de Sanitat, Plaza de España 6, 03010, Alicante, España.
| | - Pamela Pereyra-Zamora
- Unidad de Investigación de Análisis de la Mortalidad y Estadísticas Sanitarias. Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia. Campus de San Vicente del Raspeig s/n. Apartado 99, Universidad de Alicante, 03080, Alicante, España.
| | - Nayara Tamayo-Fonseca
- Unidad de Investigación de Análisis de la Mortalidad y Estadísticas Sanitarias. Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia. Campus de San Vicente del Raspeig s/n. Apartado 99, Universidad de Alicante, 03080, Alicante, España.
| | - Miguel Angel Martínez-Beneito
- Área de Desigualdades en Salud. FISABIO-CSISP, Conselleria de Sanitat, Avenida de Cataluña, 21, 46020, Valencia, España. .,Ciber de Epidemiología y Salud Pública CIBERESP, Instituto de Salud Carlos III, Melchor Fernández Almagro, 3-5 28029, Madrid, España.
| | - Oscar Zurriaga
- Área de Desigualdades en Salud. FISABIO-CSISP, Conselleria de Sanitat, Avenida de Cataluña, 21, 46020, Valencia, España. .,Servicio de Estudios Epidemiológicos y Estadísticas Sanitarias, Subdirección General de Epidemiología y Vigilancia de la Salud. Conselleria de Sanitat, Avenida de Cataluña, 21, 46020, Valencia, España. .,Ciber de Epidemiología y Salud Pública CIBERESP, Instituto de Salud Carlos III, Melchor Fernández Almagro, 3-5 28029, Madrid, España.
| | - Mónica Ballesta
- Department of Epidemiology, Regional Health Council, Murcia, Spain.
| | - Antonio Daponte
- Observatorio de Salud y Medio Ambiente de Andalucía (OSMAN). Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio, 4. Ap. Correos 2070, Granada, 18080, España.
| | - Ana Gandarillas
- Servicio de Epidemiología. Subdirección de Promoción de la Salud y Prevención. Dirección General de Atención Primaria, Consejería de Sanidad Comunidad de Madrid, C/ San Martín de Porres, n° 6, 1ª planta, 28035, Madrid, España.
| | - M Felicitas Domínguez-Berjón
- Servicio de Informes de Salud y Estudios. Subdirección de Promoción de la Salud y Prevención. Dirección General de Atención Primaria, Consejería de Sanidad Comunidad de Madrid, C/ San Martín de Porres, n° 6, 1ª planta, 28035, Madrid, España.
| | - Marc Marí-Dell'Olmo
- Ciber de Epidemiología y Salud Pública CIBERESP, Instituto de Salud Carlos III, Melchor Fernández Almagro, 3-5 28029, Madrid, España. .,Agència de Salut Pública de Barcelona, Plaça Lesseps, 1, 08023, Barcelona, España. .,Institut d'Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain.
| | - Mercè Gotsens
- Ciber de Epidemiología y Salud Pública CIBERESP, Instituto de Salud Carlos III, Melchor Fernández Almagro, 3-5 28029, Madrid, España. .,Agència de Salut Pública de Barcelona, Plaça Lesseps, 1, 08023, Barcelona, España. .,Institut d'Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain.
| | - Natividad Izco
- Dirección General de Salud Pública y Consumo, Gobierno de La Rioja, Calle Vara de Rey n° 8, 1ª planta, 26071, Logroño, España.
| | - M Concepción Moreno
- Ciber de Epidemiología y Salud Pública CIBERESP, Instituto de Salud Carlos III, Melchor Fernández Almagro, 3-5 28029, Madrid, España. .,Instituto de Salud Pública y Laboral de Navarra, C/ Leyre, 15, 31003, Pamplona, Navarra, Spain.
| | - Marc Sáez
- Ciber de Epidemiología y Salud Pública CIBERESP, Instituto de Salud Carlos III, Melchor Fernández Almagro, 3-5 28029, Madrid, España. .,Grupo de Investigación en Estadística, Econometría y Salud (GRECS), [Research Group on Statistics, Econometrics and Health (GRECS)], Universidad de Girona. Calle de la Universidad 10, Campus de Montilivi, 17071, Girona, España.
| | - Carmen Martos
- Ciber de Epidemiología y Salud Pública CIBERESP, Instituto de Salud Carlos III, Melchor Fernández Almagro, 3-5 28029, Madrid, España. .,Instituto Aragonés de Ciencias de la Salud, Avda. San Juan Bosco, n°13, 50009, Zaragoza, España.
| | - Pablo Sánchez-Villegas
- Observatorio de Salud y Medio Ambiente de Andalucía (OSMAN). Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio, 4. Ap. Correos 2070, Granada, 18080, España.
| | - Carme Borrell
- Ciber de Epidemiología y Salud Pública CIBERESP, Instituto de Salud Carlos III, Melchor Fernández Almagro, 3-5 28029, Madrid, España. .,Agència de Salut Pública de Barcelona, Plaça Lesseps, 1, 08023, Barcelona, España.
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A Monte Carlo method to estimate the confidence intervals for the concentration index using aggregated population register data. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2015; 15:82-98. [PMID: 25983615 PMCID: PMC4426159 DOI: 10.1007/s10742-015-0137-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 01/19/2015] [Accepted: 02/05/2015] [Indexed: 12/02/2022]
Abstract
In this paper, we introduce several statistical methods to evaluate the uncertainty in the concentration index (C) for measuring socioeconomic equality in health and health care using aggregated total population register data. The C is a widely used index when measuring socioeconomic inequality, but previous studies have mainly focused on developing statistical inference for sampled data from population surveys. While data from large population-based or national registers provide complete coverage, registration comprises several sources of error. We simulate confidence intervals for the C with different Monte Carlo approaches, which take into account the nature of the population data. As an empirical example, we have an extensive dataset from the Finnish cause-of-death register on mortality amenable to health care interventions between 1996 and 2008. Amenable mortality has been often used as a tool to capture the effectiveness of health care. Thus, inequality in amenable mortality provides evidence on weaknesses in health care performance between socioeconomic groups. Our study shows using several approaches with different parametric assumptions that previously introduced methods to estimate the uncertainty of the C for sampled data are too conservative for aggregated population register data. Consequently, we recommend that inequality indices based on the register data should be presented together with an approximation of the uncertainty and suggest using a simulation approach we propose. The approach can also be adapted to other measures of equality in health.
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Manderbacka K, Arffman M, Keskimäki I. Has socioeconomic equity increased in somatic specialist care: a register-based cohort study from Finland in 1995-2010. BMC Health Serv Res 2014; 14:430. [PMID: 25253175 PMCID: PMC4263122 DOI: 10.1186/1472-6963-14-430] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 09/19/2014] [Indexed: 11/17/2022] Open
Abstract
Background Equal access to health care according to need is an important goal for health policy in Finland. Earlier research in Finland and elsewhere has mainly been cross-sectional, but the results have implied that the goal has not been fully realised in somatic specialist hospital care. This study examines trends in socioeconomic equity in use of somatic specialist hospital care. Methods We used register data on somatic specialist hospital admissions among 25–84 year-old persons in Finland in 1995–2010 with individually linked register-based socio-demographic information. We calculated age-standardised admission rates per 100,000 person years by income, examined risk ratios using Poisson regression models and computed concentration indices separately for men and women. Linear trends in the socioeconomic distribution of admissions and surgical procedures were estimated with linear regression models for annual concentration indices. Results Overall, use of somatic specialist hospital care decreased steadily throughout the study period. A stepwise inverse income pattern was found in hospitalisation risk and in non-surgical admissions: the lower the income group, the higher the risk. The relative admission risk was approximately two times higher in the lowest income group compared to the highest among both genders. Few differences were found in surgical admissions. Income group differences remained stable in hospitalisations and surgical admissions, but increased in non-surgical admissions during the study period. An inverse pattern of increasing operation rates with decreasing income was found in primary hip and knee replacement operations, and in lower limb amputations. A similar pattern emerged during the study period in coronary revascularisations. There were no differences were found in lumbar fusion or lumbar disc operations, prostatectomies or appendectomies. Income group differences in hysterectomies disappeared during the study period. Conclusions While the results of the current study suggest that use of somatic specialist care declined in line with improving population health in 1995–2010, the increase of socioeconomic health differentials was only partly reflected in the distribution of somatic specialist hospital care. Further research is needed to evaluate the need to improve use and content of specialised hospital care among the low-income groups in order to improve equity in health care.
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Affiliation(s)
- Kristiina Manderbacka
- Service System Research Unit, National Institute for Health and Welfare, P, O, Box 30, 00271 Helsinki, Finland.
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Manderbacka K, Arffman M, Sund R, Karvonen S. Multiple social disadvantage does it have an effect on amenable mortality: a brief report. Int J Equity Health 2014; 13:67. [PMID: 25085285 PMCID: PMC4237818 DOI: 10.1186/s12939-014-0067-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 07/16/2014] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Most studies on inequalities in health and health-care focus on single indicators of social position, e.g. income or education. Recent research has suggested that multiple social circumstances need to be analysed simultaneously to disentangle their influence on health. In past decades mortality amenable to health-care, i.e. premature mortality that should not occur given timely and effective health-care, has increasingly been used to study the effect of health-care on health outcomes. This study elaborates the effect of social and regional deprivation and unemployment on the association between income and mortality amenable to health-care in Finland. METHODS Individual-level data for deaths were gathered by disease category between 1992 and 2008 for the resident Finnish population aged 25 to 59 years. Differences in amenable mortality and changes over time were assessed using individual-level linked register data. We used gender- and age-standardised rates and Poisson regression models to examine the simultaneous effect of these indicators on amenable mortality. RESULTS Altogether 22,663 persons aged 25-59 years died from causes amenable to health-care during the study period. An inverse pattern was found in amenable mortality for income. The mortality rate in the lowest income quintile was 98 (93-104) per 100,000 in the period 1991-1996 while in the highest group the figure was 40 (38-42) for the same period. Whereas the level of amenable mortality decreased, mortality differences between income groups steepened and amenable mortality increased in the lowest income group towards the end of the study period. Those in poor labour market position or living alone had significantly larger income differences in amenable mortality. Risk of regional deprivation was not associated with amenable mortality. CONCLUSIONS In order to prevent and treat at an early phase conditions that otherwise may lead to premature and unnecessary deaths more attention should be focused on groups with increased social and economic deprivation risk in municipal health centres with the aim at improving access to primary care. Our results also call for joint action by both health-care and social services, since health services alone cannot deal with the risks posed by accumulating social disadvantage.
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Affiliation(s)
- Kristiina Manderbacka
- National Institute for Health and Welfare, Service System Research Unit, Helsinki, FI-00271, Finland
| | - Martti Arffman
- National Institute for Health and Welfare, Service System Research Unit, Helsinki, FI-00271, Finland
| | - Reijo Sund
- National Institute for Health and Welfare, Service System Research Unit, Helsinki, FI-00271, Finland
| | - Sakari Karvonen
- Department of Social and Health Policy and Economics, Helsinki, FI-00271, Finland
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Manderbacka K, Peltonen R, Martikainen P. Amenable mortality by household income and living arrangements: a linked register-based study of Finnish men and women in 2000-2007. J Epidemiol Community Health 2014; 68:965-70. [PMID: 25059732 DOI: 10.1136/jech-2014-204272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Mortality amenable to healthcare interventions has increasingly been used as an indirect indicator of the effect of healthcare on health inequalities. Studies have consistently shown socioeconomic differences in amenable mortality, but evidence on the joint effects of multiple socioeconomic and demographic factors is limited. We examined whether income and living arrangements have an independent effect on amenable mortality taking into account other dimensions of social position. METHODS The longitudinal and yearly updated individual level data were derived from different administrative registers and obtained from Statistics Finland. The data set includes an 11% random sample of all individuals aged 25-74 years at the end of 1999 and an 80% oversample of deaths in the follow-up period between 2000 and 2007. We used Cox proportional hazard regression with appropriate weights. RESULTS We found twofold to threefold differences in amenable mortality between the top and bottom income quintiles. These differences were found to be largely attenuated by economic activity and living arrangements. We also found differences in amenable mortality by living arrangements suggesting that those living alone, as well as lone parents and those cohabiting have higher amenable mortality. These differences were largely independent of our indicators of socioeconomic position and economic activity. CONCLUSIONS While our results give indirect support to the hypothesis that income differences in amenable mortality may be at least partially due to barriers in access to care, the large independent effects of living arrangements on amenable mortality suggest that seeking care may also have an impact.
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Affiliation(s)
- Kristiina Manderbacka
- Service System Research Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Riina Peltonen
- Department of Social Research, Population Research Unit, University of Helsinki, Helsinki, Finland
| | - Pekka Martikainen
- Department of Social Research, Population Research Unit, University of Helsinki, Helsinki, Finland
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Nolasco A, Quesada JA, Moncho J, Melchor I, Pereyra-Zamora P, Tamayo-Fonseca N, Martínez-Beneito MA, Zurriaga O. Trends in socioeconomic inequalities in amenable mortality in urban areas of Spanish cities, 1996-2007. BMC Public Health 2014; 14:299. [PMID: 24690471 PMCID: PMC3983886 DOI: 10.1186/1471-2458-14-299] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 03/28/2014] [Indexed: 12/02/2022] Open
Abstract
Background While research continues into indicators such as preventable and amenable mortality in order to evaluate quality, access, and equity in the healthcare, it is also necessary to continue identifying the areas of greatest risk owing to these causes of death in urban areas of large cities, where a large part of the population is concentrated, in order to carry out specific actions and reduce inequalities in mortality. This study describes inequalities in amenable mortality in relation to socioeconomic status in small urban areas, and analyses their evolution over the course of the periods 1996–99, 2000–2003 and 2004–2007 in three major cities in the Spanish Mediterranean coast (Alicante, Castellón, and Valencia). Methods All deaths attributed to amenable causes were analysed among non-institutionalised residents in the three cities studied over the course of the study periods. Census tracts for the cities were grouped into 3 socioeconomic status levels, from higher to lower levels of deprivation, using 5 indicators obtained from the 2001 Spanish Population Census. For each city, the relative risks of death were estimated between socioeconomic status levels using Poisson’s Regression models, adjusted for age and study period, and distinguishing between genders. Results Amenable mortality contributes significantly to general mortality (around 10%, higher among men), having decreased over time in the three cities studied for men and women. In the three cities studied, with a high degree of consistency, it has been seen that the risks of mortality are greater in areas of higher deprivation, and that these excesses have not significantly modified over time. Conclusions Although amenable mortality decreases over the time period studied, the socioeconomic inequalities observed are maintained in the three cities. Areas have been identified that display excesses in amenable mortality, potentially attributable to differences in the healthcare system, associated with areas of greater deprivation. Action must be taken in these areas of greater inequality in order to reduce the health inequalities detected. The causes behind socioeconomic inequalities in amenable mortality must be studied in depth.
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Affiliation(s)
- Andreu Nolasco
- Unidad de Investigación de Análisis de la Mortalidad y Estadísticas Sanitarias, Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia, Universidad de Alicante Campus de San Vicente del Raspeig s/n, Apartado 99, 03080 Alicante, España.
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Räisänen S, Gissler M, Kramer MR, Heinonen S. Influence of delivery characteristics and socioeconomic status on giving birth by caesarean section - a cross sectional study during 2000-2010 in Finland. BMC Pregnancy Childbirth 2014; 14:120. [PMID: 24678806 PMCID: PMC3999387 DOI: 10.1186/1471-2393-14-120] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 03/26/2014] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean section (CS) rates especially without medical indication are rising worldwide. Most of indications for CS are relative and CS rates for various indications vary widely. There is an increasing tendency to perform CSs without medical indication on maternal request. Women with higher socioeconomic status (SES) are more likely to give birth by CS. We aimed to study whether giving birth by CS was associated with SES and other characteristics among singleton births during 2000–2010 in Finland with publicly funded health care. Methods Data were gathered from the Finnish Medical Birth Register. The likelihood of giving birth by CS according to CS type (planned and non-planned), parity (nulliparous vs. multiparous), socio-demographic factors, delivery characteristics and time periods (2000–2003, 2004–2007 and 2008–2010) was determined by using logistic regression analysis. SES was classified as upper white collar workers (highest SES), lower white collar workers, blue collar workers (lowest SES), others (all unclassifiable cases) and cases with missing information. Results In total, 19.8% (51,511 of 259,736) of the nulliparous women and 13.1% (47,271 of 360,727) of the multiparous women gave birth by CS. CS was associated with several delivery characteristics, such as placental abruption, placenta previa, birth weight and fear of childbirth, among both parity groups. After adjustment, the likelihood of giving birth by planned CS was reduced by 40% in nulliparous and 55% in multiparous women from 2000–2003 to 2008–2010, whereas the likelihood of non-planned CSs did not change. Giving birth by planned and non-planned CS was up to 9% higher in nulliparous women and up to 17% higher in multiparous women in the lowest SES groups compared to the highest SES group. Conclusions Giving birth by CS varied by clinical indications. Women with the lowest SES were more likely to give birth by CS, indicating that the known social disparity in pregnancy complications increases the need for operative deliveries in these women. Overall, the CS policy in Finland shows favoring a trial of labor over planned CS and reflects no inequity in healthcare services.
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Affiliation(s)
- Sari Räisänen
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, USA.
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Manderbacka K, Peltonen R, Lumme S, Keskimäki I, Tarkiainen L, Martikainen P. The contribution of health policy and care to income differences in life expectancy--a register based cohort study. BMC Public Health 2013; 13:812. [PMID: 24010957 PMCID: PMC3846484 DOI: 10.1186/1471-2458-13-812] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 09/05/2013] [Indexed: 12/02/2022] Open
Abstract
Background Growing mortality differences between socioeconomic groups have been reported in both Finland and elsewhere. While health behaviours and other lifestyle factors are important in contributing to health differences, some researchers have suggested that some of the mortality differences attributable to lifestyle factors could be preventable by health policy measures and that health care may play a role. It has also been suggested that its role is increasing due to better results in disease prevention, improved diagnostic tools and treatment methods. This study aimed to assess the impact of mortality amenable to health policy and health care on increasing income disparities in life expectancy in 1996-2007 in Finland. Methods The study data were based on an 11% random sample of Finnish residents in 1988–2007 obtained from individually linked cause of death and population registries and an oversample of deaths. We examined differences in life expectancy at age 35 (e35) in Finland. We calculated e35 for periods 1996-97 and 2006-07 by income decile and gender. Differences in life expectancies and change in them between the richest and the poorest deciles were decomposed by cause of death group. Results Overall, the difference in e35 between the extreme income deciles was 11.6 years among men and 4.2 years among women in 2006-07. Together, mortality amenable to health policy and care and ischaemic heart disease mortality contributed up to two thirds to socioeconomic differences. Socioeconomic differences increased from 1996-97 by 3.4 years among men and 1.7 years among women. The main contributor to changes was mortality amenable through health policy measures, mainly alcohol related mortality, but also conditions amenable through health care, ischaemic heart disease among men and other diseases contributed to the increase of the differences. Conclusions The results underline the importance of active health policy and health care measures in tackling socioeconomic health inequalities.
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Affiliation(s)
- Kristiina Manderbacka
- Service System Research Unit, National Institute for Health and Welfare, P,O, Box 30, Helsinki 00271, Finland.
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