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

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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

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

• Health care and health
• Need and use of care
• Use and accessibility of care
• Quality of care
• Health care programs and policies

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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

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Health and health care (1)

• Key messagein Europe, inequalities also exist in
  health problems that are potentially amenable to
  medical intervention

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Health and health care (2) Educational difference
in number of days lived between 35th and 70th
birthday, 1990s
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Health and health care (2b) Idem, including
eastern European countries
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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
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Health and health care (4)Cancer survival in the
Netherlands, 1990s
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Need and use (1)

• Key messagein Europe, differences in the
  utilization of most health services are
  according to need, except for use of specialist
  visits

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

• Rate ratios comparing lower to higher income
  groups fortotal 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

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

• Educational differences in utilisation of four
  services before and after control for health
  status

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Need and use (4) Difference of low vs. high
educated groupsin frequency of GP visits, early
2000s
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Need and use (5)Difference of low vs. high
educated groupsin frequency of visits to the
specialist
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Use and accessibility of care (1)

• Key messageLower socioeconomic groups face
  specific problems affecting use and accessibility
  of services

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Use and access (2) Health care foregone because
of costs or unavailability, by income level, 2004
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Use and access (3) Summary of inequalities in
the utilisation of preventive services, ca. 2004
Less than 10 percent difference Flu
vaccination Cholesterol check Blood
pressure control About 10 percent
difference Breast cancer screening About 25
percent difference Eye examination Colon
cancer screening
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Use and access (4)Utilization of mammography by
educational level, 2004
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Quality of care (1)

• Key messagethere is evidence for inequalities in
  quality of care delivered to patients from lower
  classes, at least for specialized services

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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)

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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)

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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)

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Programs and policies (1)

• Key messageprograms and policies can have
  different effects among different socioeconomic
  groups

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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
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Programs and policies (3) Evaluation of smoking
cessation services for deprived areas in England,
early 2000s
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
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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 systems Gate
keeping by GP Less out-of-pocket
payments Unrelated to the magnitude of
inequalities Payment methods of
physicians Public health expenditure (as of
GDP) Doctor availability
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Summary

• Inequalities exist for conditions amenable to
  medical intervention
• Utilization of health services is generally
  according to need
• Lower groups often do face specific problems with
  accessibility
• Quality of care delivered to low-class patients
  is sometimes lower
• Equity-oriented programs and policies can make a
  difference