Socioeconomic differences in the utilisation of health care services: a European overview

Anton Kunst for the international seminar

on socioeconomic differences in health care utilisation

Brussels, 30 October 2008

How large inequalities could be: poor-rich differences in child health care in Turkey, 1990s

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% died before 5th birthday

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No professionalassistence at delivery

No full immunisation inchildhood

% o

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Mid

Rich

Contents

1. Health care and health

2. Need and use of care

3. Use and accessibility of care

4. Quality of care

5. Health care programs and policies

Source of illustrations

European overviews: from the Eurothine project

data from national mortality registries, national interview surveys,

or the SHARE baseline survey

publications by Johan Mackenbach, Anton Kunst, Irina Stirbu et al

www.eurothine.org

National illustrations: from published reports and papers

Health and health care (1)

Key message

in Europe, inequalities also exist in health problems that

are potentially amenable to medical intervention

Health and health care (2) Educational difference in number of days lived between 35th and 70th birthday, 1990s

0

50

100

150

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Be

lgiu

m

Fin

lan

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Sw

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No

rwa

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ark

Sw

itze

rla

nd

Tu

rin

Ba

rce

lon

a

Ma

dri

d

Slo

ven

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Hih

g-l

ow

dif

fere

nc

e (

da

ys

)

Infectious dis.

Other avoidable

Other causes

Health and health care (2b) Idem, including eastern European countries

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Be

lgiu

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Fin

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itze

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Tu

rin

Ba

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Ma

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Hu

ng

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Cze

ch R

Po

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Lith

ua

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Est

on

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Hih

g-l

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nc

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da

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)

Infectious dis.

Other avoidable

Other causes

Health and health care (3)Specific “avoidable” causes of death

The magnitude of educational inequalities in mortality from nine

causes of death (men and women 30-64 years; 16 countries)

Tuberculosis = 14.68 Pneumonia = 5.46

Leukemia = 1.32 Cervix cancer = 3.90

Stroke, hypertension = 3.30 Rheumatic heart dis = 3.54

Asthma = 4.50 Cholecistitis = 3.62

Appendicitis etc = 4.63

Health and health care (4)Cancer survival in the Netherlands, 1990s

Need and use (1)

Key message

in Europe, differences in the utilization of

most health services are according to need,

except for use of specialist visits

Need and use (2) Differences in volume of use of several types of services

Rate ratios comparing lower to higher income groups for

total volume of use of different services, Netherlands, 2003

GP visits = 1.57 Specialist visits = 1.35

Physiotherapist = 1.19 Dentist visits = 0.91

Hospital nights = 2.07 Prescribed medicines = 1.37

Mental health care = 7.01 Social work = 5.08

Family nurse = 4.02 Alternative medicine = 0.75

Need and use (3) Most differences are according to need

Educational differences in utilisation of four services before and after

control for health status

0.6

0.8

1

1.2

1.4

1.6

1.8

2

2.2

GP visits Specialist visits Prescribedmedicines

Hospitaladmissions

Rate

Rati

o l

low

vs.

hig

h e

du

cati

on

Control age sex Plus control health

Need and use (4) Difference of low vs. high educated groupsin frequency of GP visits, early 2000’s

0.85

0.90

0.95

1.00

1.05

1.10

1.15

1.20

1.25

1.30

Rati

o lo

w v

s. h

igh

Before control After control for health

Need and use (5)Difference of low vs. high educated groupsin frequency of visits to the specialist

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1.10

Rati

o lo

w v

s. h

igh

Before control After control for health

Use and accessibility of care (1)

Key message

Lower socioeconomic groups face specific problems

affecting use and accessibility of services

Use and access (2) Health care foregone because of costs or unavailability, by income level, 2004

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5

10

15

20

25

France Germany Greece Sweden

% w

ith

fo

reg

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e c

are

Highest Mid Lowest income

Use and access (3) Summary of inequalities in the utilisation of preventive services, ca. 2004

Less than 10 percent differenceFlu vaccination

Cholesterol check

Blood pressure control

About 10 percent differenceBreast cancer screening

About 25 percent differenceEye examination

Colon cancer screening

Use and access (4)Utilization of mammography by educational level, 2004

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% w

om

en

scre

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ed

Low High educated

Quality of care (1)

Key message

there is evidence for inequalities in quality of care

delivered to patients from lower classes, at least for

specialized services

Quality of care (2)Treatment of MI patients in Finland

Rate ratio comparing the chance of recieving invasive cardiac

procedures within 2 years after myocardial infarction. Finland,

men (women)

Low vs. intermediate/high education = 0.86 (0.90)

Blue collar vs. white collar = 0.76 (0.91)

Low vs. high income = 0.75 (0.57)

Quality of care (3) Treatment of heart patients in Dutch GP practices

Rates of treatment for men according to educational level High/mid Low

- Diuretics and ACE inhibitors 64.8 62.7% (for heart failure patients)

- Aspirin 55.5 56.0% (for TIA, PAD and AP patients)

- Specialist referral 10.6 12.0% (for all patients groups above)

Quality of care (4) Experiences of patients with GP consults in Belgium

“This literature review we found that patients from lower social

classes receive:

significantly less positive socio-emotional utterances,

a more directive and a less participatory consulting style

e.g. less involvement in treatment decisions;

lower patient control over communication;

less diagnostic and treatment information,

more physical examination.”

(Willems et al, 2004)

Programs and policies (1)

Key message

programs and policies can have different effects among

different socioeconomic groups

Programs and policies (2) Invitation strategies for breast cancer screening

Quiz. Reviews of intervention studies showed that organised

breast cancer screening increase attendance among lower

social groups in different ways, except by

A: Promotion through primary

care physicians

C: Invitation letters with medical

explanations

B: Individual tailoring of

invitation letters

D: Removing financial constraints,

e.g. fees

Programs and policies (3) Evaluation of smoking cessation services for deprived areas in England, early 2000’s

SES (combination of education, housing tenure and living conditions)

% of smokers making a

quit attempt(1)

% quitters successful

after 1 year(2)

% of all smokerswho successfully

quitted(1) * (2)

Lowest 20% 2,3 13,0 0,42

Next 20 % 1,9 15,0 0,38

Mid 20% 1,6 14,8 0,37

Next 20% 1,5 18,8 0,47

Highest 20% 1,3 16,9 0,17

Programs and policies (4) health care characteristics (un-)related to inequalities in specialist visits, 13 countries, ca. 2003

Related to smaller inequalities in specialist visits

Tax-based health care systemsGate keeping by GPLess out-of-pocket payments

Unrelated to the magnitude of inequalities

Payment methods of physiciansPublic health expenditure (as % of GDP)Doctor availability

Summary

1. Inequalities exist for conditions amenable to medical intervention

2. Utilization of health services is generally according to need

3. Lower groups often do face specific problems with accessibility

4. Quality of care delivered to low-class patients is sometimes lower

5. Equity-oriented programs and policies can make a difference