A dynamic analysis of GP visiting in Ireland: 1995-2001

The influence of caregiver's migration status on child's use of healthcare services: evidence from Ireland

Large-scale international migration continues apace. From a health-care services perspective, it is important to understand the influence of migrant heritage on utilization, to allocate resources appropriately and facilitate equity. However, the differences in utilization across different migrant groups remain poorly understood, particularly so for paediatric populations. This paper contributes to filling this gap in knowledge, examining the health-care contact of children for whom their primary caregiver is foreign-born, using longitudinal data from two nationally representative surveys. The study setting is Ireland, which provides an interesting case as a small, open European country, which for the first-time experienced net inward migration in the past two decades. For both cohorts, panel regression models, adjusting for socioeconomic and health indicators, demonstrated lower utilization of general practitioner (GP) services for children of caregivers from 'less-advanced, non-Anglosphere, non-European Union (EU)' nations, relative to native-born counterparts. Relatively lower attendances at Emergency Departments and hospital nights were also observed for this group, as well as for children born to EU (non-UK) caregivers. The insights provided are instructive for policymakers for which immigration is a substantial phenomenon in current and future population demographics.

Socioeconomic inequalities in primary-care and specialist physician visits: a systematic review

Background

Utilization of primary-care and specialist physicians seems to be associated differently with socioeconomic status (SES). This review aims to summarize and compare the evidence on socioeconomic inequalities in consulting primary-care or specialist physicians in the general adult population in high-income countries.

Methods

We carried out a systematic search across the most relevant databases (Web of Science, Medline) and included all studies, published since 2004, reporting associations between SES and utilization of primary-care and/or specialist physicians. In total, 57 studies fulfilled the eligibility criteria.

Results

Many studies found socioeconomic inequalities in physician utilization, but inequalities were more pronounced in visiting specialists than primary-care physicians. The results of the studies varied strongly according to the operationalization of utilization, namely whether a physician was visited (probability) or how often a physician was visited (frequency). For probabilities of visiting primary-care physicians predominantly no association with SES was found, but frequencies of visits were higher in the most disadvantaged. The most disadvantaged often had lower probabilities of visiting specialists, but in many studies no link was found between the number of visits and SES.

Conclusion

This systematic review emphasizes that inequalities to the detriment of the most deprived is primarily a problem in the probability of visiting specialist physicians. Healthcare policy should focus first off on effective access to specialist physicians in order to tackle inequalities in healthcare.

PROSPERO registration number

CRD42019123222.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01375-1.

Free GP care and psychological health: Quasi-experimental evidence from Ireland

There is considerable ambiguity in the literature on the effect of health insurance on health. While the majority of previous analyses have examined physical health outcomes, analyses of the broader dimensions of health such as psychological health and wellbeing have been less frequent. Using data from the Irish Longitudinal Study on Ageing (TILDA) and a difference-in-differences research design, we examine the impact of free general practitioner (GP) care on psychological health among the older population and explore potential mechanisms. While we find no impact of public health insurance expansions on quality of life, life satisfaction, depression, and worry, the removal of GP fees for all those 70+ leads to a significantly lower level of perceived stress. The impact is mainly driven by poorer, sicker and single individuals. Further analyses show that removing GP fees leads to greater access to GP services and lower levels of financial stress.

Public Healthcare Entitlements and Healthcare Utilisation among the Older Population in Ireland

The use of direct out-of-pocket payments to finance general practitioner (GP) care by the majority of the population in Ireland is unusual in a European context. Currently, approximately 40% of the population have means-tested access to free GP care, while the remainder must pay the full out-of-pocket cost. In this paper, we use data from The Irish Longitudinal Study on Ageing (TILDA) to examine the impact of the current system of public healthcare entitlements on GP utilisation among the older population. Using difference-in-difference propensity score matching methods, we find significant effects of changes in public healthcare entitlements on GP utilisation (i.e. introducing user fees reduces utilisation, while removing them increases utilisation). There is limited evidence of offset effects on other types of healthcare utilisation. The results have direct implications for current Irish health policy, and add to the international literature on the effects of insurance on healthcare utilisation. Copyright © 2016 John Wiley & Sons, Ltd.

Health related quality of life two to five years after gestational diabetes mellitus: cross-sectional comparative study in the ATLANTIC DIP cohort

Background

There is no consensus on the effect of gestational diabetes mellitus (GDM) on health-related quality of life (HRQOL) for the mother in the short or long term. In this study we examined HRQOL in a group of women who had GDM in the index pregnancy 2 to 5 years previously and compared it to a group of women with normal glucose tolerance (NGT) in the index pregnancy during the same time period.

Methods

The sample included 234 women who met International Association of Diabetes Study Groups (IADPSG) criteria for GDM in the index pregnancy and 108 who had NGT. The sample was drawn from the ATLATIC-DIP (Diabetes In Pregnancy) cohort – a network of antenatal centers along the Irish Atlantic seaboard serving a population of approximately 500,000 people. HRQOL was measured using the visual analogue component of the EQ-5D-3 L instrument in a cross-sectional survey.

Results

The difference in HRQOL between GDM and NGT groups was not significant when adjusted for the effects of the covariates. HRQOL was negatively affected by increased BMI and abnormal glucose tolerance post-partum in the NGT group. Moderate alcohol consumption was positively associated with HRQOL in the NGT group only. The negative association with smoking on HRQOL was substantially higher in the GDM group.

Conclusions

A diagnosis of GDM does not appear to have an adverse effect on HRQOL, 2 to 5 years after the index pregnancy. On the contrary, its diagnosis might lead to the development of coping strategies, which, consequently attenuates the adverse effect of the subsequent acquisition of abnormal glucose tolerance post-partum on HRQOL. Women whose pregnancy was affected by GDM are more susceptible to the adverse effects on HRQOL of alcohol use and tobacco smoking.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0705-y) contains supplementary material, which is available to authorized users.

Income-related inequity in the use of GP services by children: a comparison of Ireland and Scotland

Equity of access to health care is a key component of national and international health policy, with most countries subscribing to the principle that health care should be allocated on the basis of need, rather than ability to pay or other criteria. The issue of health care entitlements for children is particularly pertinent given the strong causal links that have been demonstrated between eligibility for free care, utilisation and health outcomes. The Irish health care system is unusual in requiring the majority of the population to pay the full out-of-pocket cost of GP care. In contrast, all Scottish residents are entitled to free GP care at the point of use. This difference in public health care entitlements between Ireland and Scotland allows us to examine the impact of differences in financing structures on equity in GP care. In this paper, we use data from two nationally representative surveys of children in Ireland and Scotland to examine the degree of income-related inequity in the utilisation of GP services in both countries. We find that while the distribution of GP care is significantly pro-poor in Ireland, even after adjustment for health need, there is little or no significant inequity in GP utilisation among Scottish children. However, focusing just on children who pay the full price of GP care in Ireland, we find some evidence for a significant pro-rich distribution of GP visits. These results reflect the particular structure of health care entitlements that exist in two systems.

Eligibility for free GP care and the utilisation of GP services by children in Ireland

The majority of the Irish population pay the full out-of-pocket price of a GP visit, with only those on low incomes exempt. While there is an extensive literature analysing the impact of the Irish system of eligibility for free GP care on GP visiting rates among adults, there is a lack of evidence for children. Given the importance of socio-economic health inequalities in shaping the future outcomes of children, it is important to analyse the extent to which the current system of eligibility leads to inequities in access to GP services among Irish children. In addition, some private health insurance plans have started to offer cover for GP expenses, which adds an additional layer of complexity to the existing system of eligibility, and to date, this has not been studied. Using a large, nationally-representative data-set covering two cohorts of Irish children (9-month olds and 9-year olds), we examine the role of eligibility for free GP care in determining GP visiting rates among children. As with the adult population, the results show that, even with controls for child health, and parental and family characteristics, eligibility for free GP care is a significant determinant of GP utilisation among Irish children.

Risk of several cancers is higher in urban areas after adjusting for socioeconomic status. Results from a two-country population-based study of 18 common cancers

Some studies suggest that there are urban-rural variations in cancer incidence but whether these simply reflect urban-rural socioeconomic variation is unclear. We investigated whether there were urban-rural variations in the incidence of 18 cancers, after adjusting for socioeconomic status. Cancers diagnosed between 1995 and 2007 were extracted from the population-based National Cancer Registry Ireland and Northern Ireland Cancer Registry and categorised by urban-rural status, based on population density of area of residence at diagnosis (rural <1 person per hectare, intermediate 1-15 people per hectare, urban >15 people per hectare). Relative risks (RR) were calculated by negative binomial regression, adjusting for age, country and three area-based markers of socioeconomic status. Risks were significantly higher in both sexes in urban than rural residents with head and neck (males RR urban vs. rural = 1.53, 95 % CI 1.42-1.64; females RR = 1.29, 95 % CI 1.15-1.45), esophageal (males 1.21, 1.11-1.31; females 1.21, 1.08-1.35), stomach (males 1.36, 1.27-1.46; females 1.19, 1.08-1.30), colorectal (males 1.14, 1.09-1.18; females 1.04, 1.00-1.09), lung (males 1.54, 1.47-1.61; females 1.74, 1.65-1.84), non-melanoma skin (males 1.13, 1.10-1.17; females 1.23, 1.19-1.27) and bladder (males 1.30, 1.21-1.39; females 1.31, 1.17-1.46) cancers. Risks of breast, cervical, kidney and brain cancer were significantly higher in females in urban areas. Prostate cancer risk was higher in rural areas (0.94, 0.90-0.97). Other cancers showed no significant urban-rural differences. After adjusting for socioeconomic variation, urban-rural differences were evident for 12 of 18 cancers. Variations in healthcare utilization and known risk factors likely explain some of the observed associations. Explanations for others are unclear and, in the interests of equity, warrant further investigation.

Moral hazard and supplier-induced demand: empirical evidence in general practice

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.

The prevalence and ingredient cost of chronic comorbidity in the Irish elderly population with medication treated type 2 diabetes: a retrospective cross-sectional study using a national pharmacy claims database

Background

Comorbidity in patients with diabetes is associated with poorer health and increased cost. The aim of this study was to investigate the prevalence and ingredient cost of comorbidity in patients ≥ 65 years with and without medication treated type 2 diabetes using a national pharmacy claims database.

Methods

The Irish Health Service Executive Primary Care Reimbursement Service pharmacy claims database, which includes all prescribing to individuals covered by the General Medical Services scheme, was used to identify the study population (≥ 65 years). Patients with medication treated type 2 diabetes (T2DM) were identified using the prescription of oral anti-hyperglycaemic agents alone or in combination with insulin as a proxy for disease diagnosis. The prevalence and ingredient prescribing cost of treated chronic comorbidity in the study population with and without medication treated T2DM were ascertained using a modified version of the RxRiskV index, a prescription based comorbidity index. The association between T2DM and comorbid conditions was assessed using logistic regression adjusting for age and sex. Bootstrapping was used to ascertain the mean annual ingredient cost of treated comorbidity. Statistical significance at p < 0.05 was assumed.

Results

In 2010, 43165 of 445180 GMS eligible individuals (9.7%) were identified as having received medication for T2DM. The median number of comorbid conditions was significantly higher in those with T2DM compared to without (median 5 vs. 3 respectively; p < 0.001). Individuals with T2DM were more likely to have ≥ 5 comorbidities when compared to those without (OR = 2.82, 95% CI = 2.76-2.88, p < 0.0001). The mean annual ingredient cost for comorbidity was higher in the study population with T2DM (€1238.67, 95% CI = €1238.20 - €1239.14) compared to those without the condition (€799.28, 95% CI = €799.14 - € 799.41).

Conclusions

Individuals with T2DM were more likely to have a higher number of treated comorbid conditions than those without and this was associated with higher ingredient costs. This has important policy and economic consequences for the planning and provision of future health services in Ireland, given the expected increase in T2DM and other chronic conditions.

The role of private medical insurance in socio-economic inequalities in cancer screening uptake in Ireland

Screening is seen by many as a key element in cancer control strategies. Differences in uptake of screening related to socio-economic status exist and may contribute to differences in morbidity and mortality across socio-economic groups. Although a number of factors are likely to underlie differential uptake, differential access to subsequent diagnostic tests and/or treatment may have a pivotal role. This study examines differences in the uptake of cancer screening in Ireland related to socio-economic status. Data were extracted from SLÁN 2007 concerning uptake of breast, cervical, colorectal and prostate cancer screening in the preceding 12 months. Concentration indices were calculated and decomposed. Particular emphasis was placed in the decomposition upon the impact of private health insurance, evidenced in other work to impact on access to care within the mixed public-private Irish health system. This study found that significant differences related to socio-economic status exist with respect to uptake of cancer screening and that the main determinant of difference for breast, colorectal and prostate cancer screening was possession of private insurance. This may have profound implications for the design of cancer control strategies in countries where private insurance has a significant role, even where screening services are publicly funded and population based.

The effect of differential eligibility for free GP services on GP utilisation in Ireland

Internationally, there is extensive empirical evidence that a strong primary care-led health system is associated with improved health outcomes, increased quality of care, decreased health inequalities and lower overall health-care costs. Within primary care, factors influencing access to, and utilisation of, general practitioner (GP) services have been widely examined and this paper focuses on the role of user financial incentives. In particular, user charges for health care have been observed to deter health-care utilisation. Relative to other countries, the Irish health-care system is unusual in that the majority of the population are required to pay out-of-pocket for GP care. However, in 2005 the Irish government extended eligibility for free GP care to a further small subset of the population. Using micro-data from a nationally representative survey of the population in 2007, this paper analyses the impact of differential coverage of free GP services on GP utilisation in Ireland. Results from multivariate regression analysis indicate that GP utilisation is significantly more likely in the context of free GP care, controlling for a range of demographic, socio-economic and health factors. Interpretation of the results for the new category of coverage is complicated by possible pent-up demand and selection effects.

An extension in eligibility for free primary care and avoidable hospitalisations: a natural experiment

In the Republic of Ireland, approximately 30 per cent of the population ('medical card patients') are entitled to free GP services. Eligibility is determined primarily on the basis of an income means test. The remaining 70 per cent of the population ('private patients') must pay the full cost of GP consultations. In July 2001, eligibility for a medical card was extended to all those over 70 years of age, regardless of income. This extension in eligibility provides a natural experiment whereby we can examine the influence of access to free GP services on avoidable hospitalisations. Avoidable hospitalisations are those that are potentially avoidable with timely and effective access to primary care services or that can be treated more appropriately in a primary care setting. Using hospital discharge data for the period 1999-2004, the purpose of this paper is to test the proposition that enhanced access to GP services for the over 70s after July 2001 led to a decline in avoidable hospitalisations among this group. The results indicate that while avoidable hospitalisations for the over 70s did decline after 2001, they also fell for the under 70s, meaning that a significant difference-in-difference effect could not be identified.

Impact of discontinuity in health insurance on resource utilization

Background

This study sought to describe the incidence of transitions into and out of Medicaid, characterize the populations that transition and determine if health insurance instability is associated with changes in healthcare utilization.

Methods

2000-2004 Medical Expenditure Panel Survey (MEPS) was used to identify adults enrolled in Medicaid at any time during the survey period (n = 6,247). We estimate both static and dynamic panel data models to examine the effect of health insurance instability on health care resource utilization.

Results

We find that, after controlling for observed factors like employment and health status, and after specifying a dynamic model that attempts to capture time-dependent unobserved effects, individuals who have multiple transitions into and out of Medicaid have higher emergency room utilization, more office visits, more hospitalizations, and refill their prescriptions less often.

Conclusions

Individuals with more than one transition in health insurance status over the study period were likely to have higher health care utilization than individuals with one or fewer transitions. If these effects are causal, in addition to individual benefits, there are potentially large benefits for Medicaid programs from reducing avoidable insurance instability. These results suggest the importance of including provisions to facilitate continuous enrollment in public programs as the United States pursues health reform.

The impact of income on private patients' access to GP services in Ireland

OBJECTIVES

To examine the extent to which proximity to the income threshold for free GP care results in significant differences in GP visiting. Approximately 30% of the Irish population receives free GP care (medical card patients), while the remaining 70% pays in full (private patients). Medical card eligibility exerts a significant influence on GP visiting, but how do GP visiting rates differ among private patients on differing incomes, and has the differential in visiting among private patients changed over time?

METHODS

Using micro-data from three nationally representative surveys of the Irish population undertaken in 1987, 1995 and 2001, multivariate models of GP utilization are estimated.

RESULTS

There is little evidence that proximity to the income threshold results in significant differences in GP visiting. The most significant difference is between medical card and private patients, rather than between private patients on differing incomes. There is also little evidence that the differential in GP visiting between private patients on different incomes changed over time.

CONCLUSIONS

While recent commentary has focused on the plight of individuals just above the income threshold for free GP care, these results suggest that the key difference in GP visiting is between those with, and without, eligibility for free care. If private patients are prevented from accessing GP care due to cost, this is as much an issue for those at the top of the income distribution as for those at the bottom.

Evaluating the impact of eligibility for free care on the use of general practitioner (GP) services: a difference-in-difference matching approach

In Ireland, approximately 30% of the population ('medical card patients') are entitled to free general practitioner (GP) care while the remaining 70% ('private patients') must pay the full cost of each visit. Previous research has analysed the effect of this system on GP visiting patterns using regression methods, but to date, no attempt has been made to apply techniques from the treatment evaluation literature to this issue. Treatment evaluation techniques are commonly employed when observations are not randomly assigned to treatment and control groups; this is certainly the case here, as the primary criterion for medical card eligibility is an income below a specified income threshold (and individuals may also be granted medical cards for other reasons such as chronic ill-health). In this paper, previous Irish research, which has analysed the effect of medical card eligibility on GP visiting using regression methods, is extended to consider the use of difference-in-difference matching methods, which control for non-random selection into treatment and control groups, as well as differences in time-invariant unobserved characteristics between individuals in both groups. The results are largely consistent with earlier results using pooled cross-sectional and panel data, and confirm that medical card eligibility exerts a significant effect on GP visiting, even after controlling for observed and unobserved differences in characteristics between medical card and private patients.

Eligibility for free GP care, "need" and GP visiting in Ireland

The determinants of general practitioner (GP) visiting patterns in Ireland, in particular the role of eligibility for free GP care, are examined using microdata from a nationally representative survey of the population in 2001. Whereas most studies find that need factors such as age and health status are most important in determining GP visiting rates, the Irish situation is complicated by the distinction between medical card patients, who receive free GP visits, and private patients, who must pay for each visit. Controlling for a variety of need-related and other factors, the results show that health status and medical card eligibility are consistently most important in explaining differences in GP visiting patterns. The medical card result is particularly noteworthy; even when differences in age and other observable characteristics between medical card and private patients are taken into account, medical card patients are both more likely than private patients to visit their GP, and they visit more frequently when they do. In addition, we investigated whether individuals just above the income threshold for a medical card are disadvantaged in terms of accessing GP services in comparison with other private patients on higher incomes. We found that there is little significant difference among private patients in GP visiting rates as we move up the income distribution.

Should we brush twice a day? Determinants of dental health among young adults in Finland

We explore the determinants of dental ill-health as measured by the occurrence of caries. A recursive bivariate probit model that was derived from health production and demand theory is employed to model caries, while taking account of dental care use. The data are from a follow-up questionnaire used in a longitudinal study of the Northern Finland 1966 Birth Cohort, with respondents aged 31 (n = 5020). The factors controlled for relate to family background and health behavior during their youth, current socioecononomic variables and dental health stock. The total effects on the occurrence of caries of the explanatory variables are computed. Among females, factors increasing caries are body mass index and intake of alcohol, sugar and soft drinks, and those reducing caries are birth weight and adolescent school achievement. Among males, caries is positively related to the metropolitan residence and negatively related to education and healthy diet. Smoking increases caries, whereas dental care use, regular dental attendance and brushing teeth at least twice a day decrease caries. To promote oral health, attention should focus on policies to improve dental health education and to reduce the impacts of common risk factors.