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Davari M, Maracy MR, Khorasani E. Socioeconomic status, cardiac risk factors, and cardiovascular disease: A novel approach to determination of this association. ARYA ATHEROSCLEROSIS 2020; 15:260-266. [PMID: 32206069 PMCID: PMC7073799 DOI: 10.22122/arya.v15i6.1595] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Socioeconomic inequality is one of the important issues in cardiovascular diseases (CVDs). The aim of this study was to investigate the distribution and relation between selected cardiac risk factors, type of CVD, and the socioeconomic status (SES) in the hospitalized patients with heart disease in Isfahan, Iran. METHODS This analytical and cross-sectional study was conducted in Isfahan in 2013. The population consisted of all patients with CVD admitted to the public and private hospitals. The sample size was 721. Data collection was conducted through one researcher-made questionnaire with three sections: demographic, disease, and SES questionnaires. To determine the SES of the patients, the indicators of income, housing status, occupation, family size, and education were used. Data analysis was conducted in two statistical levels of descriptive and inferential. RESULTS 69.1% of the patients were placed in the poor status, and there was no wealthy status within the subjects. The five most frequent CVDs were chronic ischemia, unstable angina, arrhythmia, congestive heart failure (CHF), and acute myocardial infarction (MI), respectively. The three highest frequent risk factors in the patients were hypertension (HTN) (47.2%), diabetes (33.6%), and hyperlipidemia (32.6%). Regression analysis of the risk factors and the type of heart disease on the SES revealed that there were statistically significant differences between patients who were smokers (P = 0.030) and those who had valve disease (P = 0.010), adjusted for age, gender, and marital status. CONCLUSION Our findings showed that the frequency of CVD risk factors were higher in lower SES groups and thus SES can be a strong predictor for the occurrence of the CVD risk factors as well as the CVDs.
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Affiliation(s)
- Majid Davari
- Assistant Professor, Pharmaceutical Management and Economic Research Center AND Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Maracy
- Professor, Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elahe Khorasani
- PhD Candidate, Students' Scientific Research Center AND Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Schröder SL, Fink A, Richter M. Socioeconomic differences in experiences with treatment of coronary heart disease: a qualitative study from the perspective of elderly patients. BMJ Open 2018; 8:e024151. [PMID: 30429146 PMCID: PMC6252635 DOI: 10.1136/bmjopen-2018-024151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES This qualitative study aims to analyse socioeconomic differences in patients' experiences along the treatment pathway for coronary heart disease (CHD). DESIGN A longitudinal qualitative study using in-depth semistructured interviews to explore patients' experiences with treatment was conducted. We analysed the transcripts of the records according to qualitative content analysis and identified differences between patients with lower and higher socioeconomic status (SES) by comparing and contrasting the narratives. SETTING The University Hospital in Halle (Saale), Germany. PARTICIPANTS 41 elderly patients (aged 59-80 years) who suffered from CHD. RESULTS From various patient's experiences along the pathway of care which were found to differ according to SES we derived three major themes: (1) information: patients with higher SES had greater knowledge about treatment and could use medical records as sources of information; (2) illness perception: patients with lower SES focused on improving symptoms and survival, while patients with higher SES focused on physical performance and disease management; and (3) perceived role in healthcare: patients with lower SES tended to delegate responsibility to healthcare professionals. CONCLUSIONS Differences in the patient's knowledge about treatment, their perceived role in healthcare and illness perception can be the factors and mechanisms that contribute to explain socioeconomic inequalities in the treatment of CHD. These factors should be considered in quantitative studies to better understand the disparities in treatment and mortality. We suggest that improving patient-physician communication and patient knowledge can change the patient's understanding of CHD and their perceived role in healthcare and reduce inequalities in CHD treatment. TRIAL REGISTRATION NUMBER DRKS00007839.
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Affiliation(s)
- Sara Lena Schröder
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Medical Faculty, Halle (Saale), Germany
| | - Astrid Fink
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Medical Faculty, Halle (Saale), Germany
| | - Matthias Richter
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Medical Faculty, Halle (Saale), Germany
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Vaez M, Dalén M, Friberg Ö, Nilsson J, Frøbert O, Lagerqvist B, Ivert T. Regional differences in coronary revascularization procedures and outcomes: a nationwide 11-year observational study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 3:243-248. [DOI: 10.1093/ehjqcco/qcx007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/27/2017] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
The study investigated whether regional differences in choice of coronary revascularization affected outcomes in Sweden.
Methods and results
We conducted a prospective nationwide study of outcome in patients undergoing coronary artery bypass grafting (CABG, n = 47 065) or percutaneous coronary intervention (PCI, n = 140 945) from 2001 through 2011, tracked for a median of 5 years. During this period, the proportion of CABG in revascularization procedures decreased nationwide from an average of 38% to 18%e. Three-vessel disease and left main stem coronary artery stenosis were more common among CABG patients than in PCI patients. In both males and females, all-cause mortality was higher in CABG patients than in PCI patients, while repeat PCI was performed more frequently in the PCI group. CABG proportions in 21 counties ranged from 13% to 42% in females and males. The combined outcomes of repeat revascularization, non-fatal acute myocardial infarction, and death during the tracking period was recorded in 151 936 patients without ST-elevation myocardial infarction after PCI (n = 37 820, 36%) and CABG (n = 18 903, 40%). The multivariable adjusted risk of combined outcomes was higher after both PCI and CABG in both females and males in the three quartiles of counties with a smaller proportion of CABG than in the quartile of counties with the highest proportion of CABG. Similar patterns persisted after including only mortality in the analyses.
Conclusion
There are subgroups of patients who have prognostic benefits of CABG in addition to symptomatic improvement that is well documented with both PCI and CABG.
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Affiliation(s)
- Marjan Vaez
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Ole Frøbert
- Faculty of Health, Department of Cardiology, Örebro University Hospital, Örebro University, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology Section, Uppsala Clinical, Research Center, Uppsala University, Uppsala, Sweden
| | - Torbjörn Ivert
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Lumme S, Manderbacka K, Keskimäki I. Trends of relative and absolute socioeconomic equity in access to coronary revascularisations in 1995-2010 in Finland: a register study. Int J Equity Health 2017; 16:37. [PMID: 28222730 PMCID: PMC5320656 DOI: 10.1186/s12939-017-0536-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 02/14/2017] [Indexed: 11/30/2022] Open
Abstract
Background Resources for coronary revascularisations have increased substantially since the early 1990s in Finland. At the same time, ischaemic heart disease (IHD) mortality has decreased markedly. This study aims to examine how these changes have influenced trends in absolute and relative differences between socioeconomic groups in revascularisations and age group differences in them using IHD mortality as a proxy for need. Methods Hospital Discharge Register data on revascularisations among Finns aged 45–84 in 1995–2010 were individually linked to population registers to obtain socio-demographic data. We measured absolute and relative income group differences in revascularisation and IHD mortality with slope index of inequality (SII) and concentration index (C), and relative equity taking need for care into account with horizontal inequity index (HII). Results The supply of procedures doubled during the years. Socioeconomic distribution of revascularisations was in absolute and relative terms equal in 1995 (Men: SII = −12, C = −0.00; Women, SII = −30, C = −0.03), but differences favouring low-income groups emerged by 2010 (M: SII = −340, C = −0.08; W: SII = −195, C = −0.14). IHD mortality decreased markedly, but absolute and relative differences favouring the better-off existed throughout study years. Absolute differences decreased somewhat (M: SII = −760 in 1995, SII = −681 in 2010; W: SII = −318 in 1995, SII = −211 in 2010), but relative differences increased significantly (M: C = −0.14 in 1995, C = −0.26 in 2010; W: C = −0.15 in 1995, C = −0.25 in 2010). HII was greater than zero in each year indicating inequity favouring the better-off. HII increased from 0.15 to 0.18 among men and from 0.10 to 0.12 among women. We found significant and increasing age group differences in HII. Conclusions Despite large increase in supply of revascularisations and decrease in IHD mortality, there is still marked socioeconomic inequity in revascularisations in Finland. However, since changes in absolute distributions of both supply and need for coronary care have favoured low-income groups, absolute inequity can be claimed to have decreased although it cannot be quantified numerically.
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Affiliation(s)
- Sonja Lumme
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland.
| | - Kristiina Manderbacka
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland
| | - Ilmo Keskimäki
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland.,Faculty of Social Sciences, University of Tampere, Tampere, FI-33014 University of Tampere, Finland
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Evans LW, van Woerden H, Davies GR, Fone D. Impact of service redesign on the socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction: a natural experiment and electronic record-linked cohort study. BMJ Open 2016; 6:e011656. [PMID: 27797993 PMCID: PMC5093375 DOI: 10.1136/bmjopen-2016-011656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM To investigate the impact of service redesign in the provision of revascularisation procedures on the historical socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction (AMI). DESIGN Natural experiment and retrospective cohort study using linked data sets in the Secure Anonymised Information Linkage databank. NON-RANDOMISED INTERVENTION An increase in the capacity of revascularisation procedures and service redesign in the provision of revascularisation in late 2011 to early 2012. SETTING South Wales cardiac network, Census 2011 population 1 359 051 aged 35 years and over. PARTICIPANTS 9128 participants admitted to an NHS hospital with a first AMI between 1 January 2010 and 30 June 2013, with 6-months follow-up. MAIN OUTCOME MEASURE Hazard ratios (HRs) for the time to revascularisation for deprivation quintiles, age, gender, comorbidities, rural-urban classification and revascularisation facilities of admitting hospital. RESULTS In the preintervention period, there was a statistically significant decreased adjusted risk of revascularisation for participants in the most deprived quintile compared to the least deprived quintile (HR 0.80; 95% CI 0.69 to 0.92, p=0.002). In the postintervention period, the increase in revascularisation rates was statistically significant in all quintiles, and there was no longer any statistically significant difference in the adjusted revascularisation risk between the most and the least deprived quintile (HR 1.04; 95% CI 0.89 to 1.20, p<0.649). However, inequity persisted for those aged 75 years and over (HR 0.40; 95% CI 0.35 to 0.46, p<0.001) and women (HR 0.77; 95% CI 0.70 to 0.86, p<0.001). CONCLUSIONS Socioeconomic inequity of access to revascularisation was no longer apparent following redesign of revascularisation services in the south Wales cardiac network, although inequity persisted for women and those aged 75+ years. Increasing the capacity of revascularisation did not differentially benefit participants from the least deprived areas.
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Affiliation(s)
- Lloyd W Evans
- Public Health Wales Observatory, Public Health Wales, Carmarthen, UK
| | | | - Gareth R Davies
- Public Health Wales Observatory, Public Health Wales, Carmarthen, UK
| | - David Fone
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Hetemaa T, Manderbacka K, Reunanen A, Koskinen S, Keskimäki I. Socioeconomic inequities in invasive cardiac procedures among patients with incident angina pectoris or myocardial infarction. Scand J Public Health 2016; 34:116-23. [PMID: 16581703 DOI: 10.1080/14034940510032248] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aims: In many countries, systematic socioeconomic disparities have emerged in the use of invasive cardiac procedures among myocardial infarction patients and hospitalized coronary patients. This study prospectively examined socioeconomic differences in the use of cardiac procedures in a national cohort of incident coronary patients. Methods: The data were based on individual register linkages among 49,846 patients with incident angina pectoris (AP) or myocardial infarction (MI) during one-year follow-up in 1995—98 in Finland. Socioeconomic differences in invasive coronary procedures were examined using proportional hazard models. Results: The analyses showed that women, AP patients, and persons with lower socioeconomic status received fewer procedures during the one-year follow-up than men, MI patients, and those with higher socioeconomic status. Socioeconomic differences in the utilization of cardiac procedures were similar in both AP and MI groups, among both men and women, and by all socioeconomic indicators: social class, education, and income. Disparities were already emerging after the 28-day follow-up among men and women in both patient groups, and they persisted throughout the study period. Controlling for disease severity, comorbidity, and hospital district did not modify the results. Conclusions: Socioeconomic disparities in receiving invasive coronary procedures among AP patients without MI were similar to those in MI patients.
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Affiliation(s)
- Tiina Hetemaa
- National Research and Development Centre for Welfare and Health (STAKES), Outcomes and Equity Research, Helsinki, Finland.
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Coronary angiography and myocardial revascularization following the first acute myocardial infarction in Norway during 2001–2009: Analyzing time trends and educational inequalities using data from the CVDNOR project. Int J Cardiol 2016; 212:122-8. [DOI: 10.1016/j.ijcard.2016.03.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 03/13/2016] [Accepted: 03/15/2016] [Indexed: 01/31/2023]
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Schröder SL, Richter M, Schröder J, Frantz S, Fink A. Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review. Int J Cardiol 2016; 219:70-8. [PMID: 27288969 DOI: 10.1016/j.ijcard.2016.05.066] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 05/12/2016] [Indexed: 11/28/2022]
Abstract
Strong socioeconomic inequalities exist in cardiovascular mortality and morbidity. The current review aims to synthesize the current evidence on the association between socioeconomic status (SES) and access to treatment of coronary heart disease (CHD). We examined quantitative studies analyzing the relationship between SES and access to CHD treatment that were published between 1996 and 2015. Our data sources included Medline and Web of Science. Our search yielded a total of 2066 records, 57 of which met our inclusion criteria. Low SES was found to be associated with low access to coronary procedures and secondary prevention. Access to coronary procedures, especially coronary angiography, was mainly related to SES to the disadvantage of patients with low SES. However, access to drug treatment and cardiac rehabilitation was only associated with SES in about half of the studies. The association between SES and access to treatment for CHD was stronger when SES was measured based on individual-level compared to area level, and stronger for individuals living in countries without universal health coverage. Socioeconomic inequalities exist in access to CHD treatment, and universal health coverage shows only a minor effect on this relationship. Inequalities diminish along the treatment pathway for CHD from diagnostic procedures to secondary prevention. We therefore conclude that CHD might be underdiagnosed in patients with low SES. Our results indicate that there is an urgent need to improve access to CHD treatment, especially by increasing the supply of diagnostic angiographies, to reduce inequalities across different healthcare systems.
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Affiliation(s)
- Sara L Schröder
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany.
| | - Matthias Richter
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany
| | - Jochen Schröder
- Department of Internal Medicine III (Cardiology and Angiology), Martin Luther University Halle-Wittenberg, Germany
| | - Stefan Frantz
- Department of Internal Medicine III (Cardiology and Angiology), Martin Luther University Halle-Wittenberg, Germany
| | - Astrid Fink
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany
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Schröder SL, Fink A, Schumann N, Moor I, Plehn A, Richter M. How socioeconomic inequalities impact pathways of care for coronary artery disease among elderly patients: study protocol for a qualitative longitudinal study. BMJ Open 2015; 5:e008060. [PMID: 26553827 PMCID: PMC4654282 DOI: 10.1136/bmjopen-2015-008060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Several studies have identified that socioeconomic inequalities in coronary artery disease (CAD) morbidity and mortality lead to a disadvantage in patients with low socioeconomic status (SES). International studies have shown that socioeconomic inequalities also exist in terms of access, utilisation and quality of cardiac care. The aim of this qualitative study is to provide information on the impact of socioeconomic inequalities on the pathway of care for CAD, and to establish which factors lead to socioeconomic inequality of care to form and expand existing scientific theories. METHODS AND ANALYSIS A longitudinal qualitative study with 48 patients with CAD, aged 60-80 years, is being conducted. Patients have been recruited consecutively at the University Hospital in Halle/Saale, Germany, and will be followed for a period of 6 months. Patients are interviewed two times face-to-face using semistructured interviews. Data are transcribed and analysed based on grounded theory. ETHICS AND DISSEMINATION Only participants who have been informed and who have signed a declaration of consent have been included in the study. The study complies rigorously with data protection legislation. Approval of the Ethical Review Committee at the Martin-Luther University Halle-Wittenberg, Germany was obtained. The results of the study will be presented at several congresses, and will be published in high-quality peer-reviewed international journals. TRIAL REGISTRATION NUMBER This study has been registered with the German Clinical Trials Register and assigned DRKS00007839.
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Affiliation(s)
- Sara L Schröder
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Astrid Fink
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Nadine Schumann
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Irene Moor
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Alexander Plehn
- Department of Internal Medicine III (Cardiology and Angiology), Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Matthias Richter
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Mårtensson S, Gyrd-Hansen D, Prescott E, Andersen PK, Jacobsen RK, Osler M. Socio-economic position and time trends in invasive management and case fatality after acute myocardial infarction in Denmark. Eur J Public Health 2015; 26:146-52. [PMID: 26342131 DOI: 10.1093/eurpub/ckv156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lower case fatality and increased use of evidence-based invasive management incl. coronary angiography (CAG) have been reported for patients admitted with acute myocardial infarction (AMI) in the last 25 years. This article seeks to investigate whether these advances have benefitted patients in all socio-economic groups and how this has impacted on inequality in case fatality. METHODS Forty three thousand eight hundred and forty three patients admitted with AMI in the period from 2001 to 2009 were included. Socio-economic position was measured using individual information on education. Age-standardized cumulative incidence of CAG within 1, 3 and 30 days along with age-standardized case fatality within 30 and 365 days were estimated. Cox regression models were used to model the relative inequality over time. RESULTS Use of CAG within 1, 3 and 30 days increased for all educational groups over time and the inequality in CAG within 1 and 3 days seen in the beginning of the time frame was eliminated. Case fatality decreased in all educational groups and the relative inequality in 30 days case fatality decreased for women but not 365 days case fatality. No change was seen for inequality in case fatality for men. CONCLUSION Increased use of CAG within the evidence based time frame was observed along with a decrease in inequality. However, a reduction in inequality was only observed for short term case fatality, and only for women. These results suggest that inequality in case fatality is not primarily driven by inequality in invasive management of AMI.
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Affiliation(s)
- Solvej Mårtensson
- 1 Research Centre for Prevention and Health, Capital Region of Denmark, Glostrup, Denmark
| | - Dorte Gyrd-Hansen
- 2 Department of Business and economics, COHERE, University of Southern Denmark, Odense, Denmark
| | - Eva Prescott
- 3 Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Per Kragh Andersen
- 4 Department of Biostatistics, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Kart Jacobsen
- 1 Research Centre for Prevention and Health, Capital Region of Denmark, Glostrup, Denmark
| | - Merete Osler
- 1 Research Centre for Prevention and Health, Capital Region of Denmark, Glostrup, Denmark 5 Department of Public Health, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
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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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Yang D, James S, De Faire U, Alfredsson L, Jernberg T, Moradi T. Differences in undergoing cardiac procedures within three months after first myocardial infarction by country of birth in women and men: a Swedish national cohort study. ACUTE CARDIAC CARE 2015; 17:5-13. [PMID: 25806974 DOI: 10.3109/17482941.2015.1005101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine the relationship between country of birth and the utilization of coronary angiography, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) after a first-time myocardial infarction (MI). DESIGN, SETTING AND PATIENTS 117,494 MI patients of all ages who were admitted to coronary care units between 2001 and 2009 in Sweden were followed-up for three months after admission. MAIN OUTCOME MEASURES Undergoing coronary angiography, PCI or CABG after first-time MI. RESULTS proportion of patients undergoing angiography and PCI increased whereas proportion of patients undergoing CABG also delay time for all three procedures decreased over the study period. The proportion of women undergoing any of the three procedures was markedly lower and delay time longer than those of men regardless of study period and migration background. Overall foreign-born first MI patients had higher rate of angiography (HR = 1.30, 95% CI: 1.27-1.33), PCI (HR = 1.27, 95% CI: 1.24-1.30) and CABG (HR = 1.21, 95% CI: 1.15-1.28) compared with Sweden born first MI patients. After controlling for potential confounding factors in multivariable models, the overall differences vanished for angiography and reduced markedly for PCI and CABG. However, multivariable stratified analysis by specific country of birth yielded higher rate of angiography among men born in Uganda (HR = 2.11, 95% CI: 1.00-4.43) and Peru (HR = 1.98, 95% CI: 1.07-3.68) and lower rate among men born in Croatia (HR = 0.71, 95% CI: 0.52-0.99) and women born in Thailand (HR = 0.49, 95% CI: 0.35-0.94). PCI adjusted rates were higher among women born in Palestine state (HR = 2.44, 95% CI: 1.15-5.16), Iraq (HR = 1.34, 95% CI: 1.04-1.74) and Poland (HR = 1.21, 95% CI: 1.02-1.44) and rate of CABG was higher among immigrants from some parts of Asia, including men born in Sri Lanka (HR = 3.19, 95% CI: 1.43-7.12), India (HR = 1.95, 95% CI: 1.21-3.14), Vietnam (HR = 2.65, 95% CI: 1.32-5.33), Palestine State (HR = 2.11, 95% CI: 1.06-4.24), and women born in Syria (HR = 2.36, 95% CI: 1.25-4.45), Iraq (HR = 1.74, 95% CI: 1.02-2.94), and Turkey (HR = 1.70, 95% CI: 1.03-2.79). CONCLUSIONS The observed high rate of CABG for immigrants and particularly those born in some Asian countries was not explained by the potential confounding factors. A more severe coronary disease in this population might explain this high rate but needs further research. Awareness and subsequent intervention at earlier stage of coronary disease among immigrants could prolong their life and reduce the healthcare costs.
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Affiliation(s)
- Dong Yang
- Institute of Environmental Medicine, Division of Epidemiology, Karolinska Institutet , Stockholm , Sweden
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White J, Gutacker N, Jacobs R, Mason A. Hospital admissions for severe mental illness in England: changes in equity of utilisation at the small area level between 2006 and 2010. Soc Sci Med 2014; 120:243-51. [PMID: 25262312 PMCID: PMC4225455 DOI: 10.1016/j.socscimed.2014.09.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 09/16/2014] [Accepted: 09/19/2014] [Indexed: 11/18/2022]
Abstract
Severe Mental Illness (SMI) encompasses a range of chronic conditions including schizophrenia, bipolar disorder and psychoses. Patients with SMI often require inpatient psychiatric care. Despite equity being a key objective in the English National Health Service (NHS) and in many other health care systems worldwide, little is known about the socio-economic equity of hospital care utilisation for patients with SMI and how it has changed over time. This analysis seeks to address that gap in the evidence base. We exploit a five-year (2006–2010) panel dataset of admission rates at small area level (n = 162,410). The choice of control variables was informed by a systematic literature search. To assess changes in socio-economic equity of utilisation, OLS-based standardisation was first used to conduct analysis of discrete deprivation groups. Geographical inequity was then illustrated by plotting standardised and crude admission rates at local purchaser level. Lastly, formal statistical tests for changes in socio-economic equity of utilisation were applied to a continuous measure of deprivation using pooled negative binomial regression analysis, adjusting for a range of risk factors. Our results suggest that one additional percentage point of area income deprivation is associated with a 1.5% (p < 0.001) increase in admissions for SMI after controlling for population size, age, sex, prevalence of SMI in the local population, as well as other need and supply factors. This finding is robust to sensitivity analyses, suggesting that a pro-poor inequality in utilisation exists for SMI-related inpatient services. One possible explanation is that the supply or quality of primary, community or social care for people with mental health problems is suboptimal in deprived areas. Although there is some evidence that inequity has reduced over time, the changes are small and not always robust to sensitivity analyses. High bed occupancy for Severe Mental Illness (SMI) suggests limited access to care. We analyse trends in equity of inpatient use within and across small areas. Those living in deprived areas were significantly more likely to use inpatient care. Changes in this inequality between 2006 and 2010 were small and not always significant. SMI admission rates vary substantially between health care commissioning groups.
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Affiliation(s)
- Jonathan White
- Centre for Health Economics, University of York, York YO10 5DD, United Kingdom.
| | - Nils Gutacker
- Centre for Health Economics, University of York, York YO10 5DD, United Kingdom.
| | - Rowena Jacobs
- Centre for Health Economics, University of York, York YO10 5DD, United Kingdom.
| | - Anne Mason
- Centre for Health Economics, University of York, York YO10 5DD, United Kingdom.
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Gnavi R, Rusciani R, Dalmasso M, Giammaria M, Anselmino M, Roggeri DP, Roggeri A. Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI. Differences or inequities? Int J Cardiol 2014; 176:724-30. [PMID: 25183535 DOI: 10.1016/j.ijcard.2014.07.107] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 07/11/2014] [Accepted: 07/26/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Several studies have reported gender and socioeconomic differences in the use of revascularization procedures in patients with acute myocardial infarction. However, it is not clear whether these differences influence patients' survival. Moreover, most of the studies neither considered STEMI and NSTEMI separately, nor included primary PCI, which nowadays is the treatment of choice in case of AMI. In an unselected population of patients admitted to hospital with a first episode of STEMI and NSTEMI we examined gender and socioeconomic differences in the use of cardiac invasive procedures and in one-year mortality. METHODS Subjects hospitalized with a first episode of STEMI (n=3506) or NSTEMI (n=2286) were selected from the Piedmont (Italy) hospital discharge database. We considered the percentage of patients undergoing PCI, primary PCI and CABG, and in-hospital mortality. Out of hospital mortality was calculated through record linkage with the regional register. The relation between outcomes and gender or educational level was investigated using appropriate multivariate regression models adjusting for available confounders. RESULTS After adjustment for age, comorbidity and hospital characteristics, women and low educated patients had a lower probability of undergoing revascularization procedures. However, neither in-hospital, nor 30-day, nor 1-year mortality showed gender or social disparities. CONCLUSIONS Despite gender and socioeconomic differences in the use of revascularization, no differences emerged in in-hospital and 1-year mortality. These findings could suggest that patients are differently, but equitably, treated; differences are more likely due to an inability to fully adjust for clinical conditions rather than to a selection process at admission.
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Affiliation(s)
- Roberto Gnavi
- Epidemiology Unit, Regione Piemonte, Grugliasco (TO) ASL TO3, Italy.
| | | | - Marco Dalmasso
- Epidemiology Unit, Regione Piemonte, Grugliasco (TO) ASL TO3, Italy
| | - Massimo Giammaria
- Cardiology Department, Maria Vittoria Hospital, Torino ASL TO2, Italy
| | - Monica Anselmino
- Cardiology Department, San Giovanni Bosco Hospital, Torino ASL TO2, Italy
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McCallum AK, Manderbacka K, Arffman M, Leyland AH, Keskimäki I. Socioeconomic differences in mortality amenable to health care among Finnish adults 1992-2003: 12 year follow up using individual level linked population register data. BMC Health Serv Res 2013; 13:3. [PMID: 23286878 PMCID: PMC3602718 DOI: 10.1186/1472-6963-13-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 11/23/2012] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Finland decentralised its universal healthcare system and introduced market reforms in the 1990s. Despite a commitment to equity, previous studies have identified persistent socio-economic inequities in healthcare, with patterns of service use that are more pro-rich than in most other European countries. To examine whether similar socio-economic patterning existed for mortality amenable to intervention in primary or specialist care, we investigated trends in amenable mortality by income group from 1992-2003. METHODS We analysed trends in all cause, total disease and mortality amenable to health care using individual level data from the National Causes of Death Register for those aged 25 to 74 years in 1992-2003. These data were linked to sociodemographic data for 1990-2002 from population registers using unique personal identifiers. We examined trends in causes of death amenable to intervention in primary or specialist healthcare by income quintiles. RESULTS Between 1992 and 2003, amenable mortality fell from 93 to 64 per 100,000 in men and 74 to 54 per 100,000 in women, an average annual decrease in amenable mortality of 3.6% and 3.1% respectively. Over this period, all cause mortality declined less, by 2.8% in men and 2.5% in women. By 2002-2003, amenable mortality among men in the highest income group had halved, but the socioeconomic gradient had increased as amenable mortality reduced at a significantly slower rate for men and women in the lowest income quintile. Compared to men and women in the highest income quintile, the risk ratio for mortality amenable to primary care had increased to 14.0 and 20.5 respectively, and to 8.8 and 9.36 for mortality amenable to specialist care. CONCLUSIONS Our findings demonstrate an increasing socioeconomic gradient in mortality amenable to intervention in primary and specialist care. This is consistent with the existing evidence of inequity in healthcare use in Finland and provides supporting evidence of changes in the socioeconomic gradient in health service use and in important outcomes. The potential adverse effect of healthcare reform on timely access to effective care for people on low incomes provides a plausible explanation that deserves further attention.
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Affiliation(s)
- Alison K McCallum
- Directorate of Public Health and Health Policy, NHS Lothian, Waverley Gate, 2-4 Waterloo Place, Edinburgh, EH1 3EG, Scotland
| | - Kristiina Manderbacka
- National Institute for Health and Welfare, (THL), P.O. Box 30, Helsinki, FI-00271, Finland
| | - Martti Arffman
- National Institute for Health and Welfare, (THL), P.O. Box 30, Helsinki, FI-00271, Finland
| | - Alastair H Leyland
- MRC/CSO Social and Public Health Sciences Unit, Lilybank Gardens, Glasgow, G12 8RZ, Scotland
| | - Ilmo Keskimäki
- National Institute for Health and Welfare, (THL), P.O. Box 30, Helsinki, FI-00271, Finland
- School of Health Sciences, University of Tampere, Kalevantie 4, Tampere, 33014, Finland
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Socioeconomic Inequalities in the Morbidity and Mortality of Acute Coronary Events in Finland: 1988 to 2002. Ann Epidemiol 2012; 22:87-93. [DOI: 10.1016/j.annepidem.2011.10.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Revised: 10/26/2011] [Accepted: 10/26/2011] [Indexed: 11/20/2022]
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Vehko T, Sund R, Manderbacka K, Häkkinen U, Keskimäki I. Pathways leading to coronary revascularisation among patients with diabetes in Finland: a longitudinal register-based study. BMC Health Serv Res 2011; 11:180. [PMID: 21812975 PMCID: PMC3161849 DOI: 10.1186/1472-6963-11-180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 08/03/2011] [Indexed: 12/03/2022] Open
Abstract
Background Chronic conditions such as coronary heart disease (CHD) challenge health care to provide systematic and long-lasting disease management. In this study of patients who were revascularized, we examine whether treatment pathways leading to coronary revascularisation differ between patients with and without diabetes. Methods This retrospective, nationwide register-based study in Finland in 1998-2007 describes temporal trends in the proportions of 1) revascularisations performed at the first treatment period, and 2) suboptimal treatment pathways to revascularisations, i.e. pathways containing several cardiac emergency hospitalisations. Differences between patient groups were examined using a logistic regression model adjusting for age, comorbidity, and region. Results Among patients who underwent revascularisation, upward trends were found in the proportions of revascularisations performed during first hospital admission: among men with CHD alone, the percentages were 28% in 1998 and 77% in 2007; among men with insulin-dependent diabetes (IDD) they were 16% vs. 58% for the respective years; and among men with non-insulin dependent diabetes (NIDD) they were 25% vs. 69%, respectively. Among women the percentages were for non-diabetic group 32% vs. 77%; for IDD group 36% vs. 64%; and for NIDD group 33% vs. 73% for the respective years. Patients with diabetes were less likely to undergo revascularisation during the first hospital admission, in 2005-2007, the odds ratio (OR) for IDD among men was 0.52 (95% confidence interval 0.42-0.64) and for NIDD among men it was 0.79 (95% CI 0.73-0.86) compared to patients with CHD alone. The respective ORs among women were 0.59 (95% CI 0.44-0.78), and 0.83 (95% CI 0.74-0.93). Conclusions Treatment practices changed substantially during the study period to favour performing revascularisation during the first hospital admission. The large increase in coronary angioplasty operations is likely to be an important factor behind these changes. However, fewer operations are performed during the first CHD hospitalisation of diabetic patients who undergo coronary revascularisation and they experience more often emergency hospital admissions before the operation than patients without diabetes. To avoid adverse cardiac events, more attention is needed in managing diabetic CHD patients' referral pathways to revascularisation.
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Affiliation(s)
- Tuulikki Vehko
- Health and Social Services, Service Systems Research Unit, National Institute for Health and Welfare (THL), Helsinki, Finland.
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Socioeconomic inequalities in the diffusion of health technology: Uptake of coronary procedures as an example. Soc Sci Med 2011; 72:224-9. [DOI: 10.1016/j.socscimed.2010.11.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 11/05/2010] [Accepted: 11/10/2010] [Indexed: 11/24/2022]
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Vehko T, Manderbacka K, Arffman M, Reunanen A, Keskimäki I. Increasing resources effected equity in access to revascularizations for patients with diabetes. SCAND CARDIOVASC J 2010; 44:237-44. [PMID: 20586656 DOI: 10.3109/14017431.2010.494309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To examine differences in access to coronary revascularization among a cohort of coronary patients with and without diabetes in 1995-2002 in Finland and to examine how rapidly increasing resources effected socioeconomic equity in access to these operations. DESIGN An individual level nationwide register-based study of newly diagnosed CHD (coronary heart disease) patients (aged 40-79) in Finland. Rates for revascularizations were calculated per 1 000 person years. Socioeconomic differences were examined using Cox regression. RESULTS Revascularization rates increased from 354 to 443 per 1 000 person years among men with CHD and from 301 to 366 among patients with diabetes. Among women with CHD the numbers were 224 and 249 and among patients with diabetes 208 and 325. Comparing trends for first revascularization between patient groups with and without diabetes differences increased somewhat among men. Among women, revascularization rates increased more among diabetic patients. Lower revascularization rates among lower socioeconomic groups were found throughout the study period in both patient groups. CONCLUSIONS Simultaneously with large increase in cardiac operation rates, revascularization observed more common among women with diabetes compared to those without. However socioeconomic inequity in access to revascularizations among both genders remained even after increase in resources.
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Affiliation(s)
- Tuulikki Vehko
- National Institute for Health and Welfare (THL), Helsinki, Finland.
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Manderbacka K, Arffman M, Leyland A, McCallum A, Keskimäki I. Change and persistence in healthcare inequities: access to elective surgery in Finland in 1992--2003. Scand J Public Health 2009; 37:131-8. [PMID: 19124597 PMCID: PMC2841521 DOI: 10.1177/1403494808098505] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Aims: Many countries experience persistent or increasing
socioeconomic disparities in specialist care. This study examines the
socioeconomic distribution of elective surgery from 1992 to 2003 in Finland.
Methods: Administrative registers were used to identify
common elective procedures performed in all public and private hospitals in
Finland in 1992–2003. Patients’ individual
sociodemographic data came from 1990–2003 census and employment
statistics databases. First coronary revascularisation, hip and knee
replacement, lumbar disc operation, cataract extraction, hysterectomy and
prostatectomy on residents aged 25–84 years were analysed.
Age-standardized procedure rates by income quintile were calculated for both
genders, and concentration indices were developed and applied to
age-standardized procedure rates in 5% income groups for each study year.
Results: Most procedure rates increased during the study
period. Three trends emerged: declining inequality for coronary
revascularisations, an increase and then a decline in cataract extractions and
primary knee replacements among men, and positive relationships between income
and treatment for hysterectomy and lumbar disc operations.
Conclusions: Our results suggest that structural
features – uneven availability, co-payments and plurality of
provision – sustain inequity in access; decreasing inequities
reflect directed service expansion. Increased attention to collective,
prospective funding of primary and specialist ambulatory care is required to
increase equity of access to elective surgery.
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Affiliation(s)
- Kristna Manderbacka
- Health Services Research, STAKES (National Research and Development Centre for Welfare and Health), Helsinki, Finland.
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Nante N, Messina G, Cecchini M, Bertetto O, Moirano F, McKee M. Sex differences in use of interventional cardiology persist after risk adjustment. J Epidemiol Community Health 2008; 63:203-8. [PMID: 19052034 PMCID: PMC2635953 DOI: 10.1136/jech.2008.077537] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background: Studies from several countries have documented gender disparities in the management of coronary artery disease. Whether such gender disparities are seen in Italy and, if so, whether they can be explained by factors such as age and severity of illness were investigated. Methods: 77 974 Piedmontese patients, admitted between 1999 and 2002, with a primary diagnosis of myocardial infarction (ICD 410), angina (ICD 413), chronic ischaemia (ICD 414) and chest pain (ICD 786.5) were studied. The number of men and women undergoing surgical treatment was extracted and the male–female odds ratios calculated. Several risk factors and a risk adjustment technique (APR-DRG) were used to control for possible confounders. Backward stepwise multiple logistic regression was used to adjust for significant covariates. Results: Crude analysis demonstrated that gender is a discriminating factor in the probability of surgery (OR 2.11, 95% CI 2.04 to 2.19), with similar findings among those with each main diagnosis. The odds ratios decreased after adjustment for age, co-morbidity and disease severity but remained significant. Conclusions: Men and women admitted to hospitals in a region of northern Italy with a diagnosis of cardiovascular disease are treated differently and this cannot be explained by age or severity of disease.
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Affiliation(s)
- N Nante
- Health Services Research Laboratory, University of Sienna, Sienna, Italy.
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Abstract
BACKGROUND The use of a concentration index is recommended to estimate socioeconomic equity in health and health services. Methods for the analysis of concentration indices have been developed in several studies. However, these methods do not take into consideration clustering within areas, which is necessary in a comprehensive study of regional variations in equity. OBJECTIVES The study aims to develop a statistical method to assess variations in socioeconomic inequities in the use of health services in relation to need in different regions. METHODS Concentration index methods were developed further and the advantages of multilevel modeling were exploited. As an empirical example we analyzed revascularizations in 2001-2003 among the Finnish population. RESULTS The average inequity indices for the income distribution of revascularizations in Finland obtained with multilevel and standard regression modeling were comparable, but confidence intervals were smaller with multilevel modeling. Inequity indices for different areas estimated using multilevel modeling were more conservative and had smaller confidence intervals than indices estimated using the standard approach. CONCLUSIONS The proposed approach is an efficient way of estimating regional variations in the socioeconomic equity of health care use. It enables the inclusion of need in the model and takes into account the varying need for services in different population groups and areas. In addition, the advantages of using multilevel modeling to estimate indices include the possibility to take into account dependence between observations within regions and to overcome the problems associated with random error in small regions.
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Aging, health expenditure, proximity to death, and income in Finland. HEALTH ECONOMICS POLICY AND LAW 2008; 3:165-95. [PMID: 18634626 DOI: 10.1017/s174413310800443x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study revisits the debate on the 'red herring', i.e. the claim that population aging will not have a significant impact on health care expenditure (HCE), using a Finnish data set. We decompose HCE into several components and include both survivors and deceased individuals into the analyses. We also compare the predictions of health expenditure based on a model that takes into account the proximity to death with the predictions of a naïve model, which includes only age and gender and their interactions. We extend our analysis to include income as an explanatory variable. According to our results, total expenditure on health care and care of elderly people increases with age but the relationship is not as clear as is usually assumed when a naïve model is used in health expenditure projections. Among individuals not in long-term care, we found a clear positive relationship between expenditure and age only for health centre and psychiatric inpatient care. In somatic care and prescribed drugs, the expenditure clearly decreased with age among deceased individuals. Our results emphasize that even in the future, health care expenditure might be driven more by changes in the propensity to move into long-term care and medical technology than age and gender alone, as often claimed in public discussion. We do not find any strong positive associations between income and expenditure for most non-LTC categories of health care utilization. Income was positively related to expenditure on prescribed medicines, in which cost-sharing between the state and the individual is relatively high. Overall, our results indicate that the future expenditure is more likely to be determined by health policy actions than inevitable trends in the demographic composition of the population.
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Manderbacka K, Keskimäki I, Reunanen A, Klaukka T. Equity in the use of antithrombotic drugs, beta-blockers and statins among Finnish coronary patients. Int J Equity Health 2008; 7:16. [PMID: 18590524 PMCID: PMC2459171 DOI: 10.1186/1475-9276-7-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Accepted: 06/30/2008] [Indexed: 11/18/2022] Open
Abstract
Background Earlier studies have mainly reported the use of antithrombotic drugs, beta-blockers and statins among hospital patient populations or MI patients. This study aimed to describe the use of these drugs among middle-aged Finnish coronary patients and to identify patient groups in risk of being prescribed inadequate medication for secondary prevention of coronary heart disease. Methods One-year follow-up survey data from a random sample of a cohort of coronary patients were used along with register data linked to the survey. The response rate was 54% (n = 2650). The main outcome measures were use of antithrombotic drugs, beta-blockers and statins and the data were analysed using logistic regression analysis. Results Among men and women, respectively, 82% and 81% used beta-blockers, 95% and 89% used antithrombotic drugs, and 62% and 59% used statins. Younger men and men from higher socioeconomic groups were more likely to use statins, even after controlling for disease severity and comorbidity. In women, the age trend was reversed and no socioeconomic differences were found. Drug use increased with increased disease severity, but diabetes had only a slight effect. Conclusion The use of antithrombotic drugs and beta-blockers among Finnish coronary patients seemed to be rather appropriate and, to some extent, prescription practices of preventive medication varied according to patients' risk of coronary events. However, statin use was remarkably low among men with low socio-economic status, and there is need to improve preventive drug treatment among diabetic coronary patients.
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Affiliation(s)
- Kristiina Manderbacka
- National Research and Development Centre for Welfare and Health, Health Services Research, P,O,Box 220, 00531 Helsinki, Finland.
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Persistent Socio-economic Differences in Revascularization After Acute Myocardial Infarction Despite a Universal Health Care System—A Danish Study. Cardiovasc Drugs Ther 2007; 21:449-57. [DOI: 10.1007/s10557-007-6058-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Aalto AM, Weinman J, French DP, Aro AR, Manderbacka K, Keskimäki I. Sociodemographic differences in myocardial infarction risk perceptions among people with coronary heart disease. J Health Psychol 2007; 12:316-29. [PMID: 17284495 DOI: 10.1177/1359105307074270] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study examines sociodemographic differences in myocardial infarction (MI) risk perceptions among people with coronary heart disease (CHD) (N = 3130). Two variables for comparative risk perceptions were computed: (1) own risk compared to that of an average person; and (2) own risk compared to that of an average person with CHD. Comparative optimism in MI risk perceptions was common, particularly among men and those with higher education. CHD severity and psychosocial resources mediated these sociodemographic differences. These results suggest challenges for secondary prevention in CHD, particularly regarding psychosocial interventions for communicating risk information and supporting lifestyle adjustments.
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Manderbacka K, Hetemaa T, Keskimäki I, Luukkainen P, Koskinen S, Reunanen A. Are there socioeconomic differences in myocardial infarction event rates and fatality among patients with angina pectoris? J Epidemiol Community Health 2007; 60:442-7. [PMID: 16614336 PMCID: PMC2563967 DOI: 10.1136/jech.2005.041566] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Systematic socioeconomic differences in mortality have been reported among myocardial infarction (MI) patients in many countries, including Finland. The findings have been similar irrespective of country, study period, age group, or length of follow up, but few studies have examined the disparities among other groups of coronary patients. This study examined whether similar socioeconomic differences in outcomes exist among patients with angina pectoris (AP). METHODS The data were based on individual register linkages among a population based 40-79 year-old cohort of 61,350 patients with incident AP or MI during 1995-1998 in Finland. Two year coronary heart disease mortality and one year MI incidence and its 28 day case fatality was studied among AP patients using Cox's and logistic regression analysis, and the results compared with those of the MI patient group. RESULTS A clear socioeconomic pattern was found in two year coronary heart disease (CHD) mortality: the lower the socioeconomic group the higher the mortality risk. The socioeconomic patterning of mortality was similar to that found among MI patients. Controlling for comorbidity or disease severity did not change the results. Among AP patients a similar pattern was also found in MI incidence during the follow up, but no systematic socioeconomic differences were detected in its 28 day case fatality. CONCLUSIONS Socioeconomic differences in CHD outcomes also exist among angina patients. These results suggest that targeted measures of secondary prevention are needed among CHD patients with lower socioeconomic status to reduce socioeconomic disparities in fatal and non-fatal coronary events.
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Affiliation(s)
- Kristiina Manderbacka
- Outcomes and Equity Research Group, National Research and Development Centre for Welfare and Health (STAKES), PO Box 220, 00531 Helsinki, Finland.
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Aldasoro E, Calvo M, Esnaola S, Hurtado de Saracho I, Alonso E, Audicana C, Arós F, Lekuona I, Arteagoitia JM, Basterretxea M, Marrugat J. Diferencias de género en el tratamiento de revascularización precoz del infarto agudo de miocardio. Med Clin (Barc) 2007; 128:81-5. [PMID: 17288920 DOI: 10.1016/s0025-7753(07)72497-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Clinical variability in myocardial infarction (MI) regarding age, comorbidities and atypical symptoms could determine gender differences in inhospital care. This study analyzes the magnitude and determinants of differences between men and women in early reperfusion therapy in people hospitalized after MI. PATIENTS AND METHOD 2,836 patients who arrived to hospital with MI were studied (IBERICA-Basque Country study). The relative risk (RR) of receiving early reperfusion for men versus women, adjusted by age, clinical characteristics, risk factors, and pre-hospital delay was estimated. The effect decomposition methodology and the log binomial regression were applied. RESULTS 29% of patients were women with a median age of 77 years. The RR of revascularization in men compared to women was different according to age. When factors such as hypertension diabetes, Killip III-IV at admission and atypical symptoms were taken into account, statistically significant differences between sexes were not detected at 45 years old (RR=0.91; 95% CI=0.77-1.07). However, for 64 years old and over, the RR of reperfusion was 1.24 (95% CI=1.05-1.47). Both the differences by sex and the sex-age interaction were no longer statistically significant after adjusting by pre-hospital delay. CONCLUSIONS The delay to receive medical care in elderly women is responsible of gender differences in early reperfusion. It is necessary to analyze the reasons for treatment-seeking delay.
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Aalto AM, Aro AR, Weinman J, Heijmans M, Manderbacka K, Elovainio M. Sociodemographic, Disease Status, and Illness Perceptions Predictors of Global Self-ratings of Health and Quality of Life Among those with Coronary Heart Disease – One Year Follow-up Study. Qual Life Res 2006; 15:1307-22. [PMID: 16826444 DOI: 10.1007/s11136-006-0010-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2006] [Indexed: 11/29/2022]
Abstract
This one-year follow-up study (n = 130 at baseline, n =2745 at follow-up, aged 45-74 years) examined the relationship of patients' perceptions of coronary heart disease (CHD) and illness-related factors with global health status and global quality of life (QOL) ratings. The independent variables were CHD history (myocardial infarction, revascularisation), CHD severity (use of nitrates, CHD risk factors and co-morbidities) and illness perceptions. In multivariate regression analysis, CHD history and severity explained 13% of variance in global health status and 8% in global QOL ratings at the baseline. Illness perceptions increased the share of explained variance by 18% and 16% respectively. In the follow-up, illness perceptions explained a significant but modest share of variance in change in health status and QOL when baseline health status and QOL and CHD severity were adjusted for more symptoms being attributed to CHD, severe perceived consequences of CHD, as well as a weak belief in the controllability of CHD were related to poor global health status and QOL ratings. In structural path models associations of CHD severity factors were mediated by illness perceptions. The association of disease severity with dependent variables was weaker after controlling for illness perceptions. Cognitive representations of CHD contribute to both global health status and QOL ratings and they also mediate the associations between CHD severity and well-being. No gender differences were found in associations of illness perceptions with health status or QOL ratings.
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Affiliation(s)
- Anna-Mari Aalto
- Health Services Research, STAKES (National research and development centre for welfare and health), Lintulahdenkuja 4, Helsinki, Finn-00531, Finland.
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Picciotto S, Forastiere F, Stafoggia M, D'Ippoliti D, Ancona C, Perucci CA. Associations of area based deprivation status and individual educational attainment with incidence, treatment, and prognosis of first coronary event in Rome, Italy. J Epidemiol Community Health 2006; 60:37-43. [PMID: 16361453 PMCID: PMC2465521 DOI: 10.1136/jech.2005.037846] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Socioeconomic gradients in the occurrence of myocardial infarction are well known, but few studies have examined socioeconomic disparities in post-infarction outcomes. The objective of this study was to explore relations of socioeconomic status with the incidence, treatment, and outcome of first coronary event in Rome, Italy, during the period 1998-2000, examining effect modification by gender. METHODS Subjects were Rome residents aged 35-84 years who died from first acute coronary event before reaching the hospital (n=3470) or were hospitalised for first acute myocardial infarction (n=8467). Area based deprivation status and patients' educational attainment were the exposure variables. The outcomes were: incidence of coronary event; recanalisation at the index hospitalisation and fatality within 28 days of hospitalisation; cardiac readmissions and fatality between 28 days and one year of index hospitalisation. RESULTS Incidence rates increased as area based deprivation status increased; the effect was stronger among women than among men (men RR=1.40, 95%CI:1.30, 1.50, women RR=1.78, 95%CI:1.60, 1.98, most compared with least deprived). Rates of recanalisation were significantly lower in the most deprived patients than in the least deprived (OR=0.77, 95%CI:0.59, 0.99) and in the less educated than in the highly educated (OR=0.73, 95%CI:0.58, 0.90). Associations of short term fatality with area based deprivation status and educational attainment were weak and inconsistent. However, neither deprivation status nor education was associated with one year outcomes. CONCLUSIONS Area based deprivation status is strongly related to incidence of coronary events, and more so among women than among men. Deprivation status and educational attainment are weakly and inconsistently associated with short term fatality but seem not to influence one year prognosis of acute myocardial infarction. Deprived and less educated patients experience limited access to recanalisation procedures.
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Affiliation(s)
- Sally Picciotto
- Dipartimento di Epidemiologia, ASL RM/E, Via di Santa Costanza, 53, 00198 Roma, Italy.
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Kattainen A, Salomaa V, Jula A, Antero Kesäniemi Y, Kukkonen-Harjula K, Kähönen M, Majahalme S, Moilanen L, Nieminen MS, Aromaa A, Reunanen A. Gender differences in the treatment and secondary prevention of CHD at population level. SCAND CARDIOVASC J 2006; 39:327-33. [PMID: 16352484 DOI: 10.1080/14017430500233417] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Treatment and secondary prevention measures, received by persons with coronary heart disease (CHD), are insufficiently known at the moment. The aim of this study was to investigate the state of treatment and secondary prevention of CHD in a population-based sample and to analyze possible gender differences in different age groups. DESIGN 300 men and 300 women with CHD were identified from a nationally representative health examination survey with 88% participation rate, carried out in Finland in 2000-2001. RESULTS Revascularization had been performed on 34% (95% confidence interval 29, 40%) of men and 13% (8, 18%) of women. Moreover, 76% (71, 81%) of the men and 63% (57, 69%) of the women used antithrombotic medications. Two thirds of both men and women used beta-blockers and one third lipid-lowering medication. Smoking was more common among men, whereas obesity and high total cholesterol concentration were more common among women. CONCLUSIONS Secondary prevention of CHD is far from optimal and there are gender differences in the care of CHD.
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Affiliation(s)
- Anna Kattainen
- Department of Health and Functional Capacity, National Public Health Institute, Helsinki and Turku, Finland.
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Barreto SM, Kalache A, Giatti L. Does health status explain gender dissimilarity in healthcare use among older adults? CAD SAUDE PUBLICA 2006; 22:347-55. [PMID: 16501747 DOI: 10.1590/s0102-311x2006000200012] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study investigates the extent to which gender dissimilarity in healthcare use in later life is explained by variation in health and social-economic statuses. It is based on a nationwide sample in Brazil of 12,757 men and 16,186 women aged 60+ years. Individuals with great difficulties or unable to perform at least one daily living activity and/or to walk 100m were classified as "established disability". Those who had interrupted their activities in the previous 15 days because of a health problem were regarded as "temporarily disabled". The remaining we classified as "healthy". These categories were analyzed by multinomial logistic regression, taking "healthy" as the reference category. Prevalences of established disability were 6% among men and 11% among women. Temporary disabilities were 7.9% and 10.1%, respectively. Poor health status was associated with increased use of healthcare among men and women, but men and women differed significantly in relation to use pattern after adjustment for age, health status, and income. Older women were greater consumers of outpatient services and older men of inpatient care.
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Affiliation(s)
- Sandhi Maria Barreto
- Department of Social and Preventive Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Av. Prof, Alfredo Balena 190, Belo Horizonte, MG 30130-100, Brazil.
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Arber S, McKinlay J, Adams A, Marceau L, Link C, O'Donnell A. Patient characteristics and inequalities in doctors’ diagnostic and management strategies relating to CHD: A video-simulation experiment. Soc Sci Med 2006; 62:103-15. [PMID: 16002197 DOI: 10.1016/j.socscimed.2005.05.028] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2003] [Accepted: 05/11/2005] [Indexed: 10/25/2022]
Abstract
Numerous studies examine inequalities in health by gender, age, class and race, but few address the actions of primary care doctors. This factorial experiment examined how four patient characteristics impact on primary care doctors' decisions regarding coronary heart disease (CHD). Primary care doctors viewed a video-vignette of a scripted consultation where the patient presented with standardised symptoms of CHD. Videotapes were identical apart from varying patients' gender, age (55 versus 75), class and race, thereby removing any confounding factors from the social context of the consultation or other aspects of patients' symptomatology or behaviour. A probability sample of 256 primary care doctors in the UK and US viewed these video-vignettes in a randomised experimental design. Gender of patient significantly influenced doctors' diagnostic and management activities. However, there was no influence of social class or race, and no evidence of ageism in doctors' behaviour. Women were asked fewer questions, received fewer examinations and had fewer diagnostic tests ordered for CHD. 'Gendered ageism' was suggested, since midlife women were asked fewest questions and prescribed least medication appropriate for CHD. Primary care doctors' behaviour differed significantly by patients' gender, suggesting doctors' actions may contribute to gender inequalities in health.
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Affiliation(s)
- Sara Arber
- Department of Sociology, Centre for Research on Ageing and Gender, University of Surrey, Guildford, Surrey GU2 7XH, UK.
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Coory MD, Walsh WF. Rates of percutaneous coronary interventions and bypass surgery after acute myocardial infarction in Indigenous patients. Med J Aust 2005; 182:507-12. [PMID: 15896178 DOI: 10.5694/j.1326-5377.2005.tb00016.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 04/07/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare rates of percutaneous coronary interventions (PCI) and bypass surgery after acute myocardial infarction (AMI) in Indigenous and non-Indigenous patients. DESIGN Cohort study of public-sector patients who were followed up for 1 year using administrative hospital data. PARTICIPANTS AND SETTING We followed up 14 683 public-sector patients admitted to Queensland hospitals for AMI between 1998 and 2002. Of these, 558 (3.8%) identified as Indigenous. OUTCOME MEASURES Rates of PCI and bypass surgery, adjusted for differences between the Indigenous and non-Indigenous cohorts according to age, sex, socioeconomic status, remote residence, hospital characteristics, and comorbidities. RESULTS The adjusted rate for PCI during the index admission was significantly lower by 39% (rate ratio [RR], 0.61; 95% CI, 0.38-0.98) among Indigenous versus non-Indigenous patients with AMI; the adjusted rate for subsequent PCI was significantly lower by 28% (RR, 0.72; 95% CI, 0.54-0.96). Adjusted rates for bypass surgery were similar in the two cohorts. For any coronary procedure (ie, PCI or bypass surgery), the adjusted rate was significantly lower by 22% (RR, 0.78; 95% CI, 0.64-0.94) among Indigenous patients with AMI. Diabetes, chronic renal failure, pneumonia, and chronic rheumatic fever were at least twice as common among Indigenous patients with AMI as in the rest of the cohort, and chronic bronchitis and emphysema and heart failure were at least 60% more common. If a patient had at least one comorbidity, then their probability of having a coronary procedure was reduced by 40%. CONCLUSIONS There are likely to be several reasons for the lower rates of coronary procedures among Indigenous patients, but their high rates of comorbidities and the association of comorbidities with lower procedure rates was an important finding. As investment in primary care can reduce the prevalence and severity of comorbidities, we suggest that adequate primary health care is a prerequisite for effective specialist care.
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Affiliation(s)
- Michael D Coory
- Health Information Centre, Queensland Health, Brisbane, Australia.
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Manderbacka K. Exploring gender and socioeconomic differences in treatment of coronary heart disease. Eur J Public Health 2005; 15:634-9. [PMID: 16051653 DOI: 10.1093/eurpub/cki050] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Earlier studies on gender and socioeconomic differences in the treatment of coronary heart disease have focused mainly on structural features of the health-care system on the one hand and on coronary patients' psychosocial characteristics on the other. The aim of this exploratory qualitative study was to trace key points in the pathways of treatment where patients' experience varies and which can contribute to gender and socioeconomic differences in treatment. METHODS The data consist of 30 interviews among persons diagnosed with or suspected to have coronary heart disease in the Health 2000, a representative cross-sectional interview and health examination survey. Purposive sampling was used to ensure variation in gender, socioeconomic status and disease severity. The data were analysed using qualitative content analysis. RESULTS Gender and socioeconomic differences were found in two key points in the pathways of treatment: doctor-patient interaction and the organization of primary care. The three features commonly distinguished in doctor-patient interaction, i.e. treatment decision-making, information exchange and interpersonal relationship, were all found to be relevant. A second key point was organization of primary care in terms of both access to examinations and care, and continuity of care. CONCLUSIONS These results should sensitize us to gender and socioeconomic differences in coronary patients' problems in access to and continuity of care, as well as to potential problem areas in doctor-patient interaction.
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Affiliation(s)
- Kristiina Manderbacka
- Outcomes and Equity Research Group, National Research and Development Centre for Welfare and Health (STAKES), Helsinki, Finland.
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Morris RW, Whincup PH, Papacosta O, Walker M, Thomson A. Inequalities in coronary revascularisation during the 1990s: evidence from the British regional heart study. Heart 2005; 91:635-40. [PMID: 15831650 PMCID: PMC1768900 DOI: 10.1136/hrt.2004.037507] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate the influence of age and social circumstances on probability of revascularisation among British men. DESIGN Prospective population based study SETTING 24 medium sized British towns, none of which contained a hospital undertaking coronary artery bypass surgery. SUBJECTS 5814 surviving participants of the BRHS (British regional heart study), aged 52-73 years, with no history of revascularisation when responding to a questionnaire in November 1992. MAIN OUTCOMES Incident coronary revascularisations, as documented in general practitioner records, over the following 7.1 years and coronary angiography investigations reported by men in a further questionnaire in November 1996. RESULTS 160 men underwent at least one revascularisation during this period (4.2/1000 person-years). In multifactorial analysis, which included adjustment for incidence of major coronary heart disease or angina, a lower incidence of revascularisation was found among men aged over 65 years in November 1992 (hazard ratio 0.62, 95% confidence interval (CI) 0.44 to 0.87), among men with manual occupations (0.73, 95% CI 0.53 to 1.02), among men living in households possessing no car (0.44, 95% CI 0.24 to 0.80) or one car (0.60, 95% CI 0.42 to 0.87) compared with two or more cars, among council tenants (0.49, 95% CI 0.25 to 0.97), and among men living outside southern England (0.71, 95% CI 0.51 to 0.99). Only car ownership was related to the incidence of diagnostic angiography: the odds ratio for angiography for those owning fewer than two cars was 0.62 (95% CI 0.42 to 0.89). CONCLUSION During the 1990s, there were major inequalities in the probability of undergoing coronary revascularisation between British men according to socioeconomic status, age, and geographic location.
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Affiliation(s)
- R W Morris
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London NW3 2PF, UK.
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Aalto AM, Heijmans M, Weinman J, Aro AR. Illness perceptions in coronary heart disease. Sociodemographic, illness-related, and psychosocial correlates. J Psychosom Res 2005; 58:393-402. [PMID: 16026654 DOI: 10.1016/j.jpsychores.2005.03.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Revised: 02/01/2005] [Accepted: 03/15/2005] [Indexed: 12/31/2022]
Abstract
OBJECTIVES This study examined illness perceptions (IP) and their correlates in coronary heart disease (CHD). METHODS The sample of the questionnaire study (n = 3130 at baseline and n = 2745 at 1-year follow-up, aged 45-74 years) was drawn from the drug reimbursement register, which covers persons with various drug-treated conditions. Independent variables were CHD severity and history, vicarious experiences, and psychosocial resources. RESULTS Men attributed their CHD more often to risk behaviours and internal factors (own attitude/behaviour), while women perceived stress as the cause of their CHD more often. Women also perceived more symptoms associated with CHD but reported less severe consequences. CHD severity was the most important correlate of IP and also predicted change in IP at the follow-up. Stronger perceived competence was related to weaker illness identity, stronger control/cure, and less severe consequences. CONCLUSIONS Although disease-related factors are powerful correlates of CHD-related illness cognitions, also social and psychosocial factors are related to IP.
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Affiliation(s)
- Anna-Mari Aalto
- Effectiveness and Equity Research group, STAKES, Helsinki, Finland.
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West S, Nguyen MP, Mkocha H, Holdsworth G, Ngirwamungu E, Kilima P, Munoz B. Gender equity and trichiasis surgery in the Vietnam and Tanzania national trachoma control programmes. Br J Ophthalmol 2004; 88:1368-71. [PMID: 15489474 PMCID: PMC1772400 DOI: 10.1136/bjo.2004.041657] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To calculate the gender distribution of trichiasis cases in trachoma communities in Vietnam and Tanzania, and the gender distribution of surgical cases, to determine if women are using surgical services proportional to their needs. METHODS Population based data from surveys done in Tanzania and Vietnam as part of the national trachoma control programmes were used to determine the rate of trichiasis by gender in the population. Surgical records provided data on the gender ratio of surgical cases. RESULTS The rates of trichiasis in both countries are from 1.4-fold to sixfold higher in females compared to males. In both countries, the female to male rate of surgery was the same or even higher than the female to male rate of trichiasis in the population. CONCLUSIONS These data provide assurance of gender equity in the provision and use of trichiasis surgery services in the national programmes of these two countries. Such simple analyses should be used by other programmes to assure gender equity in provision and use of trichiasis surgery services.
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Affiliation(s)
- S West
- Dana Center for Preventive Ophthalmology, Johns Hopkins University, Baltimore, MD, USA.
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Hetemaa T, Keskimäki I, Salomaa V, Mähönen M, Manderbacka K, Koskinen S. Socioeconomic inequities in invasive cardiac procedures after first myocardial infarction in Finland in 1995. J Clin Epidemiol 2004; 57:301-8. [PMID: 15066691 DOI: 10.1016/j.jclinepi.2003.07.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2003] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We examined socioeconomic disparities in coronary procedure rates after first events among hospitalized myocardial infarction (MI) patients. STUDY DESIGN AND SETTING Information on MI patients in 1995 in Finland was obtained from the Finnish Cardiovascular Disease Register Project. Data on comorbidity, invasive treatments, hospitalizations, mortality, and socioeconomic status were obtained by linking data from the Finnish Hospital Discharge Register, cause of death register, population census, and the health insurance register using personal identity numbers. RESULTS In 1995, 5172 patients aged 40 to 74 years were hospitalized for first MI. This corresponds to age-standardized event rates of 354/100,000 for men and 152/100,000 for women. Within 2 years, 33% of men and 21% of women underwent an invasive coronary procedure. Men in the lowest income third underwent 25% (95% confidence interval [CI] 12-36) fewer procedures than men in the highest third. Among women, the corresponding difference was 43% (95% CI 24-57). These disparities persisted throughout the 2-year follow-up, and they were not reduced by adjustment for comorbidity or hospital district. CONCLUSION Socioeconomic disparities were observed in receipt of invasive cardiac procedures. More attention should be paid to equitable distribution of scarce health care resources.
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Affiliation(s)
- Tiina Hetemaa
- National Research and Development Centre for Welfare and Health (STAKES), Outcome and Equity Research, Lintulahdenkuja 4, 00530, Helsinki, Finland.
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Keskimäki I. How did Finland's economic recession in the early 1990s affect socio-economic equity in the use of hospital care? Soc Sci Med 2003; 56:1517-30. [PMID: 12614702 DOI: 10.1016/s0277-9536(02)00153-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The study evaluates the changes in socio-economic equity in the use of general hospital care in Finland from the late 1980s to the mid 1990s. In the early 1990s the Finnish economy plunged into a deep recession which slashed over 10% of GDP and resulted in a 12% decrease in national health expenditure. At the same time, the administration and financing of specialised health services were reformed. The impact on general hospital care was controversial: budgets were reduced but better productivity increased the supply of many services. According to the study, data, based on individual linkage of nationwide hospital registers to disposable family income data in population censuses, overall acute general hospital admission rates among Finns aged 25-74 increased by over 10% from 1988 to 1996. For some surgical procedures, such as cataract, coronary revascularisation and some orthopaedic operations, rates more than doubled. In both years, lower-income groups generally used hospital care more than the better-off. However, there was a slight shift towards a pro-rich distribution, mainly due to a larger increase in surgical care among the high-income groups. In 1988 the lowest income quintile used 8% and in 1996 15% fewer operations than the highest. For individual procedures and surgical diagnostic categories, the general trends of increasing disparities were similar. Despite cuts in expenditures in the early 1990s, the Finnish general hospital system based on public funding and provision managed to increase the supply of services. However, this increase coincided with widening socio-economic discrepancies in the use of surgical services. The paper proposes that these increasing inequities were due to certain features of the Finnish health care system which create social discrepancies in access to hospital care. These include the high profile of the private sector in specialised ambulatory care and in the supply of some elective procedures, and semi-private public hospital services requiring supplementary payments from patients.
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