Identifying inequitable healthcare in older people: systematic review of current research practice

Association between kidney function, frailty and receipt of invasive management after acute coronary syndrome

BACKGROUND

Reduced estimated glomerular filtration rate (eGFR) is associated with lower use of invasive management and increased mortality after acute coronary syndrome (ACS). The reasons for this are unclear.

METHODS

A retrospective clinical cohort study was performed using data from the English National Institute for Health Research Health Informatics Collaborative (2010-2017). Multivariable logistic regression was used to investigate whether eGFR<90 mL/min/1.73 m2 was associated with conservative ACS management and test whether (a) differences in care could be related to frailty and (b) associations between eGFR and mortality could be related to variation in revascularisation rates.

RESULTS

Among 10 205 people with ACS, an eGFR of <60 mL/min/1.73m2 was found in 25%. Strong inverse linear associations were found between worsening eGFR category and receipt of invasive management, on a relative and absolute scale. People with an eGFR <30 mL compared with ≥90 mL/min/1.73 m2 were half as likely to receive coronary angiography (OR 0.50, 95% CI 0.40 to 0.64) after non-ST-elevation (NSTE)-ACS and one-third as likely after STEMI (OR 0.30, 95% CI 0.19 to 0.46), resulting in 15 and 17 per 100 fewer procedures, respectively. Following multivariable adjustment, the ORs for receipt of angiography following NSTE-ACS were 1.05 (95% CI 0.88 to 1.27), 0.98 (95% CI 0.77 to 1.26), 0.76 (95% CI 0.57 to 1.01) and 0.58 (95% CI 0.44 to 0.77) in eGFR categories 60-89, 45-59, 30-44 and <30, respectively. After STEMI, the respective ORs were 1.20 (95% CI 0.84 to 1.71), 0.77 (95% CI 0.47 to 1.24), 0.33 (95% CI 0.20 to 0.56) and 0.28 (95% CI 0.16 to 0.48) (p<0.001 for linear trends). ORs were unchanged following adjustment for frailty. A positive association between the worse eGFR category and 30-day mortality was found (test for trend p<0.001), which was unaffected by adjustment for frailty.

CONCLUSIONS

In people with ACS, lower eGFR was associated with reduced receipt of invasive coronary management and increased mortality. Adjustment for frailty failed to change these observations. Further research is required to explain these disparities and determine whether treatment variation reflects optimal care for people with low eGFR.

TRIAL REGISTRATION NUMBER

NCT03507309.

Inequality in uptake of bowel cancer screening by deprivation, ethnicity and smoking status: cross-sectional study in 86 850 citizens

BACKGROUND

Survival from colorectal cancer depends on stage at detection. In England, bowel cancer mortality has historically been highest in deprived areas. During the initial stages of the COVID-19 pandemic, it was necessary to temporarily halt many screening programmes, which may have led to inequalities in uptake since screening restarted.

METHODS

Cross-sectional data from the Bristol, North Somerset and South Gloucestershire Systemwide Dataset were analyzed. Associations of baseline characteristics with uptake of bowel screening were examined using logistic regression.

RESULTS

Amongst 86 850 eligible adults aged 60-74 years, 5261 had no screening record. There was little evidence of association between no screening and sex (adjusted odds ratio 0.95 (95% confidence interval 0.90, 1.02)). Absence of screening record was associated with deprivation (1.26 (1.14, 1.40) for the most compared with the least deprived groups), smoking (1.11 (1.04, 1.18)) compared with no smoking record and black (1.36 (1.09, 1.70)) and mixed (1.08 (1.01, 1.15)) ethnicity compared with white ethnicity.

CONCLUSIONS

In a data set covering a whole NHS Integrated Care Board, there was evidence of lower uptake of bowel cancer screening in adults living in more deprived areas, of minority ethnic groups and who smoked. These findings may help focus community engagement work and inform research aimed at reducing inequalities.

What can the citations of systematic reviews of ethical literature tell us about their use?-an explorative empirical analysis of 31 reviews

Background

Systematic reviews of ethical literature (SREL) aim at providing an overview of ethical issues, arguments, or concepts on a specific ethical topic. As SREL are becoming more common, their methodology and possible impact are increasingly subjected to critical considerations. Because they analyse and synthetise normative literature, SREL are likely to be used differently than typical systematic reviews. Still, the uses and the expected purposes of SREL were, to date, mainly theoretically discussed. Our explorative study aimed at gaining preliminary empirical insights into the actual uses of SREL.

Methods

Citations of SREL in publications, both scientific and non-scientific, were taken as proxy for SREL uses. The citations of 31 published SREL were systematically searched on Google Scholar. Each citation was qualitatively analysed to determine its function. The resulting categorisation of SREL citations was further quantitatively investigated to unveil possible trends.

Results

The analysis of the resulting sample of SREL citations (n=1812) showed that the selected SREL were mostly cited to support claims about ethical issues, arguments, or concepts, but also to merely mention the existence of literature on a given topic. In this sample, SREL were cited predominantly within empirical publications in journals from various academic fields, indicating a broad, field-independent use of such systematic reviews. The selected SREL were also used as methodological orientations either for the conduct of SREL or for the practical and ethically sensitive conduct of empirical studies.

Conclusions

In our sample, SREL were rarely used to develop guidelines or to derive ethical recommendations, as it is often postulated in the theoretical literature. The findings of this study constitute a valuable preliminary empirical input in the current methodological debate on SREL and could contribute to developing strategies to align expected purposes with actual uses of SREL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-023-02341-y.

Does the presence of health insurance and health facilities improve access to healthcare for major morbidities among Indigenous communities and older widows in India? Evidence from India Human Development Surveys I and II

In this paper, we examine whether access to treatment for major morbidity conditions is determined by the social class of the person who needs treatment. Secondly, we assess whether health insurance coverage and the presence of a PHC have any significant impact on the utilisation of health services, either public or private, for treatment and, more importantly, whether the presence of health insurance and PHC modify the treatment use behaviour for the two excluded communities of interest namely Indigenous communities and older widows using data from two rounds (2005 and 2012) of the nationally representative India Human Development Survey (IHDS). We estimated a multilevel mixed effects model with treatment for major morbidity as the outcome variable and social groups, older widows, the presence of a PHC and the survey wave as the main explanatory variables. The results confirmed access to treatment for major morbidity was affected by social class with Indigenous communities and older widows less likely to access treatment. Health insurance coverage did not have an effect that was large enough to induce a positive change in the likelihood of accessing treatment. The presence of a functional PHC increased the likelihood of treatment for all social groups except Indigenous communities. This is not surprising as Indigenous communities generally live in locations where the terrain is more challenging and decentralised healthcare up to the PHC might not work as effectively as it does for others. The social class to which one belongs has a significant impact on the ability of a person to access healthcare. Efforts to address inequity needs to take this into account and design interventions that are decentralised and planned with the involvement of local communities to be effective. Merely addressing one or two barriers to access in an isolated fashion will not lead to equitable access.

Do Patients With Intersectional Disadvantage Have Poorer Outcomes From Osteoarthritis Management Programs? A Tapered Balancing Study of Patient Outcomes From the Good Life With Osteoarthritis in Denmark Program

OBJECTIVE

To investigate whether adults with potential multiple social disadvantage have poorer outcomes following attendance in an osteoarthritis (OA) management program (OAMP), and if so, what might determine this result.

METHODS

Among consecutive knee OA attendees of the Good Life With Osteoarthritis in Denmark (GLA:D) OAMP in Denmark we defined a group with potential "intersectional disadvantage" based on self-reported educational attainment, country of birth, and citizenship. Outcomes of this group were compared with GLA:D participants who were native Danish citizens with higher educational attainment. Outcomes were pain intensity, Knee Injury and Osteoarthritis Outcome Score (KOOS) quality of life subscale score, and the EuroQol 5-domain instrument in 5 levels (EQ-5D-5L) score at 3 and 12 months. After data preprocessing, we used entropy balancing to sequentially control for differences between the groups in baseline covariates. Mean between-group differences in outcomes were estimated by weighted linear regression.

RESULTS

Of 18,448 eligible participants, 250 (1.4%) were nonnative/foreign citizens with lower education. After balancing for differences in baseline score and in administrative and demographic characteristics, they had poorer outcomes than higher-educated native Danish citizens on pain intensity and EQ-5D-5L score at both follow-up points (e.g., between-group mean differences in pain visual analog scale [0-100] at 3 and 12 months: 3.4 [95% confidence interval (95% CI) -0.5, 7.3] and 6.2 [95% CI 1.7, 10.7], respectively). Differences in KOOS quality of life subscale score, were smaller or absent. Balancing for differences on baseline score, comorbidity, self-efficacy, and depression had the greatest effect on reducing observed outcome inequalities.

CONCLUSION

Outcome inequalities widened following OAMP attendance, particularly at longer-term follow-up, but the magnitude of differences was generally modest and inconsistent across outcome measures. Tailoring content to reduce outcome inequalities may be indicated, but improving access appears the greater priority.

Are older patients less likely to be treated for pancreatic cancer? A systematic review and meta-analysis

Pancreatic cancer is the seventh commonest cause of cancer-related death worldwide. Although prognosis is poor, both surgery and adjuvant chemotherapy improve survival. However, it has been suggested that not all pancreatic cancer patients who may benefit from treatment receive it. This systematic review and meta-analysis investigated the existence of age-related inequalities in receipt of first-line pancreatic cancer treatment. Medline, Embase, Cochrane Library and grey literature were searched for population-based studies investigating treatment receipt, reported by age, for patients with primary pancreatic cancer from inception until 4th June 2020, and updated 5th August 2021. Studies from countries with universal healthcare were included, to minimise influence of health system-related economic factors. A modified version of the Newcastle-Ottawa Scale was used to assess risk of bias. Random-effects meta-analysis was undertaken comparing likelihood of treatment receipt in older versus younger patients. Sensitivity and subgroup analyses were conducted. Eighteen papers were included; 12 independent populations were eligible for meta-analysis. In most studies, < 10% of older patients were treated. Older age (generally ≥65) was significantly associated with reduced receipt of any treatment (OR=0.14, 95% CI 0.10-0.21, n = 12 studies), surgery (OR=0.15, 95% CI 0.09-0.24, n = 9 studies) and chemotherapy as a primary treatment (OR=0.13, 95% CI 0.07-0.24, n = 5 studies). The effect of age was independent of methodological quality, patient population or time-period of patient diagnosis and remained in studies with confounder adjustment. The mean quality score of included studies was 6/8. Inequalities in receipt of healthcare interventions across social groups is a recognised concern internationally. This review shows that older age is significantly, and consistently, associated with non-receipt of treatment in pancreatic cancer. However, there are risks and side-effects associated with pancreatic cancer treatment. Further research on what influences patient and professional treatment decision-making is required to better understand these apparent inequalities.

Assessing equity and quality indicators for older people – Adaptation and validation of the Assessing Care of Vulnerable Elders (ACOVE) checklist for the Portuguese care context

Background

Development has promoted longer and healthier lives, but the rise in the proportion of older adults poses new challenges to health systems. Susceptibilities of older persons resulting from lower knowledge about services availability, health illiteracy, lower income, higher mental decline, or physical limitations need to be identified and monitored to assure the equity and quality of health care. The aim of this study was to develop equity indicators for the Assessing Care of Vulnerable Elders (ACOVE)-3 checklist and perform the first cross-cultural adaptation and validation of this checklist into Portuguese.

Methods

A scoping literature review of determinants or indicators of health (in)equity in the care of older people was performed. A total of 5 language experts and 18 health professionals were involved in the development and validation of the equity and quality indicators through expert opinion and focus groups. Data collected from focus groups was analyzed through directed or conventional content analysis. The usefulness of the indicators was assessed by analyzing the clinical records of 30 patients.

Results

The literature review revealed that there was a worldwide gap concerning equity indicators for older people primary health care. A structured and complete checklist composed of equity and quality indicators was obtained, validated and assessed. A significant number of non-screened quality or equity related potential occurrences that could have been avoided if the proposed indicators were implemented were detected. The percentage of non-registered indicators was 76.6% for quality and 96.7% for equity.

Conclusions

Applying the proposed checklist will contribute to improve the monitoring of the clinical situation of vulnerable older people and the planning of medical and social actions directed at this group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03104-5.

Glycosylated hemoglobin level, race/ethnicity, and cognition in midlife and early old age

Empirical evidence linking racial/ethnic differences in glycosylated hemoglobin levels (HbA1c) to cognitive function in midlife and early old age is limited. We use biomarker data from the Health and Retirement Study (HRS, 2006-2014), on adults 50-64 years at baseline (57-73 years by 2014), and fit multinomial logistic regression models to assess the association between baseline HbA1c, cognitive function (using Langa-Weir classifications) and mortality across 8-years. Additionally, we test for modification effects by race/ethnicity. In age- and sex-adjusted models high HbA1c level was associated with lower baseline cognition and higher relative risk ratios (RRR; vs. normal cognition) for cognitive impairment no dementia (CIND; RRR= 2.3; 95%CI=[1.38;3.84]; p<0.01), and dementia (RRR= 4.00; 95%CI=[1.76;9.10]; p<0.01). Adjusting for sociodemographic, behavioral risk factors, and other health conditions explained the higher RRR for CIND and attenuated the RRR for dementia by approximately 30%. HbA1c levels were not linked to the slope of cognitive decline, and we found no evidence of modification effects for HbA1c by race/ethnicity. Targeting interventions for glycemic control in the critical midlife period can protect baseline cognition and buffer against downstream development of cognitive impairment. This can yield important public health benefits and reductions in burdens associated with cognitive impairment, particularly among race/ethnic minorities who are at higher risk for metabolic diseases.

Development and validation of a search filter to identify equity-focused studies: reducing the number needed to screen

Background

Health inequalities, worse health associated with social and economic disadvantage, are reported by a minority of research articles. Locating these studies when conducting an equity-focused systematic review is challenging due to a deficit in standardised terminology, indexing, and lack of validated search filters. Current reporting guidelines recommend not applying filters, meaning that increased resources are needed at the screening stage.

Methods

We aimed to design and test search filters to locate studies that reported outcomes by a social determinant of health. We developed and expanded a ‘specific terms strategy’ using keywords and subject headings compiled from recent systematic reviews that applied an equity filter. A ‘non-specific strategy’ was compiled from phrases used to describe equity analyses that were reported in titles and abstracts, and related subject headings. Gold standard evaluation and validation sets were compiled. The filters were developed in MEDLINE, adapted for Embase and tested in both. We set a target of 0.90 sensitivity (95% CI; 0.84, 0.94) in retrieving 150 gold standard validation papers. We noted the reduction in the number needed to screen in a proposed equity-focused systematic review and the proportion of equity-focused reviews we assessed in the project that applied an equity filter to their search strategy.

Results

The specific terms strategy filtered out 93-95% of all records, and retrieved a validation set of articles with a sensitivity of 0.84 in MEDLINE (0.77, 0.89), and 0.87 (0.81, 0.92) in Embase. When combined (Boolean ‘OR’) with the non-specific strategy sensitivity was 0.92 (0.86, 0.96) in MEDLINE (Embase 0.94; 0.89, 0.97). The number needed to screen was reduced by 77% by applying the specific terms strategy, and by 59.7% (MEDLINE) and 63.5% (Embase) by applying the combined strategy. Eighty-one per cent of systematic reviews filtered studies by equity.

Conclusions

A combined approach of using specific and non-specific terms is recommended if systematic reviewers wish to filter studies for reporting outcomes by social determinants. Future research should concentrate on the indexing standardisation for equity studies and further development and testing of both specific and non-specific terms for accurate study retrieval.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0567-x) contains supplementary material, which is available to authorized users.