Disparities in access to health care in three French regions

Socio-economic position and sudden cardiac death: a Danish nationwide study

AIMS

The aim of this study was to examine differences in incidence rates of all-cause mortality (ACM) and sudden cardiac death (SCD) in persons of differing socio-economic position (SEP).

METHODS AND RESULTS

All deaths in Denmark from 1 January to 31 December 2010 (1 year) were included. Autopsy reports, death certificates, discharge summaries, and nationwide health registries were reviewed to identify cases of SCD. Socio-economic position was measured as either household income or highest achieved educational level and analysed separately. Hazard rates were calculated using univariate and multivariable Cox regression models adjusting for age, sex, and selected comorbidities. A total of 53 452 deaths were included, of which 6820 were classified as SCDs. Incidence rates of ACM and SCD increased with age and were higher in the lower SEP groups. The greatest difference in SCD incidence was found between the low and high education level groups, with an incidence rate ratio of 5.1 (95% confidence interval 3.8-6.8). The hazard ratios for ACM and SCD were significantly higher for low SEP groups, independent of comorbidities. Compared with the highest income group, the low-income group had adjusted hazard ratios of ACM and SCD that were 2.17 (2.01-2.34) and 1.72 (1.67-1.76), respectively.

CONCLUSION

We observed an inverse association between both income and education level and the risk of ACM and SCD in the general population, which persisted independently of baseline comorbidities. Our results indicate a need for further research into the mechanisms behind socio-economic disparities in healthcare and targeted preventative strategies.

Potentially avoidable hospitalizations and associated factors among older people in French Guiana using the French National Health Data System

Knowing the prevalence of potentially avoidable hospitalizations (PAHs) and the factors associated with them is essential if preventive action is to be taken. Studies on PAHs mainly concern adults, and very few have been carried out in South America. To the best of our knowledge, there has been no study on PAHs in French Guiana, particularly among older adults. This case-control study aimed to estimate the prevalence of PAHs in the Guianese population aged over 65 and to analyze their associated factors. We used the 2017-2019 data from the French National Health Service database (Système National des Données de Santé). The patients were age- and sex-matched 1 : 3 with controls without any PAH in 2019. Factors associated with PAHs were investigated through two conditional logistic regression models [one including the Charlson comorbidity index (CCI) and one including each comorbidity of the CCI], with calculation of the adjusted odds ratio (aOR) and 95% confidence interval (CI). The PAH incidence was 17.4 per 1000 inhabitants. PAHs represented 6.6% of all hospitalizations (45.6% related to congestive heart failure or hypertension). A higher CCI was associated with PAHs [aOR 2.2 (95% CI: 1.6, 3.0) and aOR 4.8 (95% CI: 2.4, 9.9) for 1-2 and ≥3 comorbidities, respectively, versus 0], as was immigrant health insurance status [aOR 2.3 (95% CI: 1.3, 4.2)]. Connective tissue disease, chronic pulmonary disease, congestive heart failure, diabetes, and peripheral vascular disease were comorbidities associated with an increased risk of PAHs. While the prevention of PAHs among immigrants is probably beyond the reach of the Guianese authorities, primary care and a public health policy geared toward prevention should be put in place for the French Guianese population suffering from cardiovascular disease in order to reduce PAHs.

Heterogeneity of glycaemic phenotypes in type 1 diabetes

AIMS/HYPOTHESIS

Our study aims to uncover glycaemic phenotype heterogeneity in type 1 diabetes.

METHODS

In the Study of the French-speaking Society of Type 1 Diabetes (SFDT1), we characterised glycaemic heterogeneity thanks to a set of complementary metrics: HbA1c, time in range (TIR), time below range (TBR), CV, Gold score and glycaemia risk index (GRI). Applying the Discriminative Dimensionality Reduction with Trees (DDRTree) algorithm, we created a phenotypic tree, i.e. a 2D visual mapping. We also carried out a clustering analysis for comparison.

RESULTS

We included 618 participants with type 1 diabetes (52.9% men, mean age 40.6 years [SD 14.1]). Our phenotypic tree identified seven glycaemic phenotypes. The 2D phenotypic tree comprised a main branch in the proximal region and glycaemic phenotypes in the distal areas. Dimension 1, the horizontal dimension, was positively associated with GRI (coefficient [95% CI]) (0.54 [0.52, 0.57]), HbA1c (0.39 [0.35, 0.42]), CV (0.24 [0.19, 0.28]) and TBR (0.11 [0.06, 0.15]), and negatively with TIR (-0.52 [-0.54, -0.49]). The vertical dimension was positively associated with TBR (0.41 [0.38, 0.44]), CV (0.40 [0.37, 0.43]), TIR (0.16 [0.12, 0.20]), Gold score (0.10 [0.06, 0.15]) and GRI (0.06 [0.02, 0.11]), and negatively with HbA1c (-0.21 [-0.25, -0.17]). Notably, socioeconomic factors, cardiovascular risk indicators, retinopathy and treatment strategy were significant determinants of glycaemic phenotype diversity. The phenotypic tree enabled more granularity than traditional clustering in revealing clinically relevant subgroups of people with type 1 diabetes.

CONCLUSIONS/INTERPRETATION

Our study advances the current understanding of the complex glycaemic profile in people with type 1 diabetes and suggests that strategies based on isolated glycaemic metrics might not capture the complexity of the glycaemic phenotypes in real life. Relying on these phenotypes could improve patient stratification in type 1 diabetes care and personalise disease management.

Persistent income-based disparities in clinical outcomes of cardiac surgery across the United States: A contemporary appraisal

Objective

Although national efforts have aimed to improve the safety of inpatient operations, income-based inequities in surgical outcomes persist, and the evolution of such disparities has not been examined in the contemporary setting. We sought to examine the association of community-level household income with acute outcomes of cardiac procedures over the past decade.

Methods

All adult hospitalizations for elective coronary artery bypass grafting/valve operations were tabulated from the 2010-2020 Nationwide Readmissions Database. Patients were stratified into quartiles of income, with records in the 76th to 100th percentile designated as highest and those in the 0 to 25th percentile as lowest. To evaluate the change in adjusted risk of in-hospital mortality, complications, and readmission over the study period, estimates were generated for each income level and year.

Results

Of approximately 1,848,755 hospitalizations, 406,216 patients (22.0%) were classified as highest income and 451,988 patients (24.4%) were classified as lowest income. After risk adjustment, lowest income remained associated with greater likelihood of in-hospital mortality (adjusted odds ratio, 1.61, 95% CI, 1.51-1.72), any postoperative complication (adjusted odds ratio, 1.19, CI, 1.15-1.22), and nonelective readmission within 30 days (adjusted odds ratio, 1.07, CI, 1.05-1.10). Overall adjusted risk of mortality, complications, and nonelective readmission decreased for both groups from 2010 to 2020 (P < .001). Further, the difference in risk of mortality between patients of lowest and highest income decreased by 0.2%, whereas the difference in risk of major complications declined by 0.5% (both P < .001).

Conclusions

Although overall in-hospital mortality and complication rates have declined, low-income patients continue to face greater postoperative risk. Novel interventions are needed to address continued income-based disparities and ensure equitable surgical outcomes.

Regional variations in vaccination against COVID-19 in Germany

Vaccination willingness against COVID-19 is generally perceived as low. Moreover, there is large heterogeneity across and within countries. As a whole, Germany has average vaccination rates compared to other industrialized countries. However, vaccination rates in the 16 different German federal states differ by more than 20 percentage points. We describe variation in vaccination rates on the level of the 400 German counties using data on all vaccinations carried out until December 2022. Around 52-72% of that variation can be explained by regional differences in demographic characteristics, housing, education and political party preferences. We find indications that the remaining part may be due to differences in soft factors such as risk aversion, trust in the German government, trust in science, and beliefs in conspiracy theories regarding the origins of the Corona virus. We conclude that improving the trust in science and the fight against conspiracy theories may possibly be effective tools to improve vaccination rates and effectively fight pandemics.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Evaluating the Impact of Teleconsultations on Access to Ambulatory Primary Care in Medically Underserved Areas: A National Observational Cross-Sectional Multicenter Study

Introduction: Access to care is a major public health concern particularly in medically underserved areas (MUAs) (Zones d'Interventions Prioritaires). Teleconsultations were legalized in France in 2010, however, have been reimbursed by the national health insurance since 2018. Large-scale studies assessing the impact of teleconsultations on access to care are limited. The objective of this study was to evaluate the impact of teleconsultations in MUAs at a national scale. Methods: An observational, multicenter cross-sectional study was conducted in seven teleconsultation centers. Teleconsultations were included if they were with patients living in France and received ambulatory care at primary ambulatory care settings by registered medical doctors between August 1 and November 30, 2021. Each center provided a randomized sample of 3,000 case data per month, yielding a total of 84,000 patients. Teleconsultation incidence was measured in MUAs and non-MUAs as the primary outcome. Results: In total, 25.1% of French patients lived in MUAs, with a mean age of 30.1 ± 0.08 years. Incidence of teleconsultations was 1,964 per 100,000 compared with 787 per 100,000 in non-MUAs (p < 0.0001). Teleconsultations were mostly performed during the day (88.6%), on weekdays (90.6%), were booked (88.3%), involved a general practitioner (GP) (89.0%), and were carried out as a video consultation (96.5%). The median delay to access was 60 min for GPs. Discussion: This was the largest study of teleconsultations in France and the first in the world to pool data from competing telemedicine companies. The incidence of teleconsultations was higher in MUAs, which may show that teleconsultations improve access to care. Clinical Trial Registration number: NCT05311241.

Association between socio-economic status and estimated atherosclerotic cardiovascular disease risk: results from a middle-aged population-based study

OBJECTIVES

The association between cardiovascular disease (CVD) risk and socio-economic status (SES) remains poorly studied. The purpose of this study was to investigate the relationship between SES and estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among the general UK Biobank population.

STUDY DESIGN

This was a population-based study.

METHODS

Among 311,928 volunteers (47.7% men) of the UK Biobank population, SES was assessed by a questionnaire, and ASCVD risk was calculated using pooled cohort equation models. Associations between SES and ASCVD risk were estimated using multiple gender-specific regressions.

RESULTS

The findings from this study showed that men had higher estimated 10-year ASCVD risk than women (8.6% vs 2.7%; P < 0.001), higher education level (38.3% vs 36.2%; P < 0.001), higher income level (31.0% vs 25.1%; P < 0.001), higher levels of employment (65.4% vs 60.5%; P < 0.001) and higher scores of Townsend deprivation (P < 0.001). Using the multiple logistic regression model, a decreased 10-year ASCVD risk in men was associated with high income level (odds ratio [OR] = 0.64 [95% confidence interval {CI} 0.61-0.68]; P < 0.001), high educational level (OR = 0.71 [95% CI 0.68-0.74]; P < 0.001), higher Townsend deprivation quintile (OR = 0.81 [95% CI 0.78-0.85]; P < 0.001) and employed status (OR = 0.74 [95% CI 0.69-0.80]; P < 0.001). The same results were observed in women, with high income level (OR = 0.68 [95% CI 0.55-0.68]; P < 0.001), high educational level (OR = 0.87 [95% CI 0.82-0.93]; P < 0.001), higher Townsend deprivation quintile (OR = 0.74 [95% CI 0.69-0.80]; P < 0.001) and employed status (OR = 0.53 [95% CI 0.45-0.63]; P < 0.001) being associated with a lower 10-year ASCVD risk. When considering the false discovery rate logworth analysis, SES factors presented a similar contribution to CVD risk as lifestyle factors.

CONCLUSIONS

Health policies should consider the SES factors identified in this study, in addition to traditional risk factors, when designing prevention campaigns for CVD. Further research is required to improve the ASCVD risk prediction models among different SES variables.

Women's health in migrant populations: a qualitative study in France

BACKGROUND

In 2019, there are 6.5 million migrants living in France. Numerous quantitative studies show inequalities in access and quality of care, in particular in women's health. This study aimed to explore migrant women's experience of gynaecological care.

METHODS

We conducted 17 semi-structured in-depth interviews with migrant women in Toulouse (France). We used a Grounded Theory approach to perform the analysis.

RESULTS

Although migrant women were generally satisfied with the gynaecological care received, they also reported dysfunctions. Positive elements were the French health insurance system, the human qualities of the healthcare providers and the performance of the health system. Although reassuring, the structured framework was perceived to have little flexibility. This was sometimes felt as oppressive, paternalistic or discriminatory. These obstacles, amplified by the women's lifestyle instability and precariousness, the language barrier and the difficulty to understand a totally new healthcare system, made women's health care and, especially, preventive care, a difficult-to-achieve and low-priority objective for the women.

CONCLUSIONS

Migrant women's overall satisfaction with the healthcare system contrasted with the known health inequalities in these populations. This is a good example of the concept of acculturation. Healthcare professionals need to make an introspective effort to prevent the emergence of stereotypes and of discriminatory and paternalistic behaviours. A better understanding and respect of the other person's culture is an indispensable condition for intercultural medicine, and thus for reducing the health inequalities that migrant women experience.

Health-related biological and non-biological consequences of forgoing healthcare for economic reasons

Forgoing healthcare for economic reasons has been previously associated with adverse health outcomes, including a higher risk of hospitalization, a lower quality of life, and worse self-reported health. However, the exact cause-to-effect relation between forgoing healthcare and health-related outcomes has been insufficiently described. Here, we investigate the prospective health consequences of forgoing healthcare for economic reasons using data from “ReBus” (N = 400), a prospective study examining the health consequences of forgoing healthcare (Baseline: 2008–2013, Follow-up: 2014–2016). Using regression models, we explored the baseline determinants of forgoing healthcare, including socioeconomic, demographic, and pre-existing health-risk factors, and examined the associations between forgoing healthcare at baseline and health deterioration at follow-up, using highly pertinent biomarkers (glucose, glycated hemoglobin, lipids, blood pressure) and SF-36 questionnaire data.

Low income, low occupation, low education, and smoking were associated with higher odds of forgoing healthcare at baseline. Forgoing healthcare for economic reasons at baseline was subsequently related to detrimental changes in glucose, high-density lipoprotein cholesterol (HDL), and blood pressure (BP) at follow-up, independently of baseline socioeconomic factors (Glucose-β = 0.19, 95%CI[0.03;0.34], HDL-β = -0.07, 95%CI[-0.14;0.01], BP-β = 3.30, 95%CI[-0.01;6.60]). Moreover, we found strong associations between forgoing healthcare and adverse SF-36 health scores at follow-up, with individuals forgoing healthcare systematically displaying worse health scores (6%–11% lower scores).

For the first time, we show that forgoing healthcare for economic reasons predicts adverse health-related consequences 2–8 years later. Our findings shall further encourage the implementation of public health measures aimed at identifying individuals who forgo healthcare and preventing the adverse health consequences of unmet medical needs.

Variation in end-of-life care and hospital palliative care among hospitals and local authorities: A preliminary contribution of big data

BACKGROUND

Many studies explore the clinical and ethical dimensions of care at the end-of-life, but fewer use administrative data to examine individual and geographic differences, including the use of palliative care.

AIM

Provide a population-based perspective on end-of-life and hospital palliative care among local authorities and hospitals in France.

DESIGN

Retrospective cohort study of care received by 17,928 decedents 65 and over (last 6 months of life), using the French national health insurance database.

RESULTS

55.7% of decedents died in acute-care hospitals; 79% were hospitalized in them at least once; 11.7% were admitted at least once for hospital palliative care. Among 31 academic medical centers, intensive care unit admissions ranged from 12% to 67.4%; hospital palliative care admissions, from 2% to 30.6%. Across local authorities, for intensive care unit days and hospital palliative care admissions, the ratios between the values at the third and the first quartile were 2.4 and 1.5. The odds of admission for hospital palliative care or to an intensive care unit for more than 7 days were more than twice as high among people ⩽85 years (aOR = 2.11 (1.84-2.43) and aOR = 2.59 (2.12-3.17), respectively). The odds of admission for hospital palliative care were about 25% lower (p = 0.04) among decedents living in local authorities with the lowest levels of education than those with the highest levels.

CONCLUSION

The variation we document in end-of-life and hospital palliative care across different categories of hospitals and 95 local authorities raises important questions as to what constitutes appropriate hospital use and intensity at the end-of-life.

The Waiting Game - How Cooperation Between Public and Private Hospitals Can Help Reduce Waiting Lists

Prolonged waiting to access health care is a primary concern for nations aiming for comprehensive effective care, due to its adverse effects on mortality, quality of life, and government approval. Here, we propose two novel bargaining frameworks to reduce waiting lists in two-tier health care systems with local and regional actors. In particular, we assess the impact of 1) trading patients on waiting lists among hospitals, the 2) introduction of the role of private hospitals in capturing unfulfilled demand, and the 3) hospitals’ willingness to share capacity on the system performance. We calibrated our models with 2008–2018 Chilean waiting list data. If hospitals trade unattended patients, our game-theoretic models indicate a potential reduction of waiting lists of up to 37%. However, when private hospitals are introduced into the system, we found a possible reduction of waiting lists of up to 60%. Further analyses revealed a trade-off between diagnosing unserved demand and the additional expense of using private hospitals as a back-up system. In summary, our game-theoretic frameworks of waiting list management in two-tier health systems suggest that public–private cooperation can be an effective mechanism to reduce waiting lists. Further empirical and prospective evaluations are needed.

Inégalités sociales de santé et médecine d’urgence

En France, le système de santé est basé sur un principe d’universalité et les indicateurs macroscopiques y sont satisfaisants. Toutefois, des inégalités de santé persistent touchant particulièrement les populations vulnérables. Celles-ci peuvent voir s’ériger des barrières financières, institutionnelles ou cognitives qui entravent leur accès aux soins et participent à l’altération de leur état de santé. L’exercice de la médecine d’urgence n’est pas exempté des problématiques soulevées par ces inégalités sociales de santé qu’il s’agisse : du rôle des services d’urgence dans la sanctuarisation de l’accès aux soins ; des pathologies urgentes plus fréquentes ou plus graves observées parmi les populations les plus vulnérables ; de la qualité des soins administrés qui est parfois suboptimale. La première partie de cet article indique ce qui définit la vulnérabilité d’une population puis il présente les spécificités des prises en charge aux urgences. Il détaille ensuite les barrières à l’accès aux soins qui persistent ainsi que les répercussions du renoncement sur le recours aux services d’urgence. Enfin, l’exemple du contexte actuel de la pandémie du Sars-Cov2 permet de mettre en lumière les nombreuses interactions qui existent entre vulnérabilité et état de santé. Les questions de l’organisation de l’offre de soins en amont des urgences et des conditions réelles de son accessibilité pour tous sont des éléments fondamentaux qui impactent la pratique de la médecine d’urgence. Il appartient aussi aux professionnels de s’en saisir et de mobiliser avec force les décideurs publics sur ces sujets.

Inequalities in avoidable hospitalisation in large urban areas: retrospective observational study in the metropolitan area of Milan

OBJECTIVE

Significant inequalities in access to healthcare system exist between residents of world megacities, even if they have different healthcare systems. The aim of this study was to estimate avoidable hospitalisations in the metropolitan area of Milan (Italy) and explore inequalities in access to healthcare between patients and across their areas of residence.

DESIGN

Retrospective observational study.

SETTING

Public and accredited private hospitals in the metropolitan area of Milan. Data obtained from the hospital discharge database of the Italian Health Ministry.

PARTICIPANTS

472 579 patients hospitalised for ambulatory care sensitive conditions and resident in the metropolitan area of Milan from 2005 to 2016.

OUTCOME MEASURE

Age-adjusted rates of avoidable hospitalisations; OR for hospital admissions with ambulatory care sensitive conditions.

METHODS

Age-adjusted rates of avoidable hospitalisations in the metropolitan area of Milan were estimated from 2005 to 2016 using direct standardisation. For the hospitalised population, multilevel logistic regression model with patient random effects was used to identify patients, hospitals and municipalities' characteristics associated with risk of avoidable hospitalisation in the period 2012-2016.

RESULTS

The rate of avoidable hospitalisation in Milan fell steadily between 2005 and 2016 from 16.6 to 10.5 per 1000. Among the hospitalised population, the odds of being hospitalised with an ambulatory care sensitive condition was higher for male (OR 1.42, 95% CI 1.36 to 1.48), older (OR 1.012, 95% CI 1.01 to 1.014), low-educated (elementary school vs degree OR 4.23, 95% CI 3.72 to 4.81) and single (vs married OR 2.08, 95% CI 2.01 to 2.16) patients with comorbidities (OR 1.47, 95% CI 1.38 to 1.56); avoidable admissions were more frequent in public non-teaching hospitals while municipality's characteristics did not appear to be correlated with hospitalisation for ambulatory care sensitive conditions.

CONCLUSIONS

The health system in metropolitan Milan has experienced a reduction in avoidable hospitalisations between 2005 and 2016, quite homogeneously across its 134 municipalities. The study design allowed to explore inequalities among the hospitalised population for which we found specific sociodemographic disadvantages.

Forgoing health care under universal health insurance: the case of France

OBJECTIVES

We investigate the reliability of a survey question on forgone healthcare services for financial reasons, based on analysis of actual healthcare use over the 3-year period preceding response to the question. We compare the actual use of different health services by patients who report having forgone health care to those who do not.

METHODS

Based on a prospective cohort study (CONSTANCES), we link survey data from enrolled participants to the Universal Health Insurance (UHI) claims database and compare use of health services of those who report having forgone health care to controls. We present multivariable logistic regression models and assess the odds of using different health services.

RESULTS

Compared to controls, forgoing care participants had lower odds of consulting GPs (OR = 0.83; 95% CI 0.73, 0.93), especially specialists outside hospitals (gynecologists: 0.74 (0.69, 0.78); dermatologists: 0.81 (0.78-0.85); pneumologists 0.82 (0.71-0.94); dentists 0.71 (0.68, 0.75)); higher odds of ED visits (OR = 1.25; 95% CI 1.19, 1.31); and no difference in hospital admissions (OR = 1.02; 95% CI 0.97, 1.09). Participants with lower occupational status and income had higher odds of forgoing health care.

CONCLUSIONS

The perception of those who report having forgone health care for financial reasons is consistent with their lower actual use of community-based ambulatory care (CBAC). While UHI may be necessary to improve healthcare access, it does not address the social factors associated with the population forgoing health care for financial reasons.

What explains the regional variation in the use of general practitioners in Australia?

BACKGROUND

Regional variation in the use of health care services is widespread. Identifying and understanding the sources of variation and how much variation is unexplained can inform policy interventions to improve the efficiency and equity of health care delivery.

METHODS

We examined the regional variation in the use of general practitioners (GPs) using data from the Social Health Atlas of Australia by Statistical Local Area (SLAs). 756 SLAs were included in the analysis. The outcome variable of GP visits per capita by SLAs was regressed on a series of demand-side factors measuring population health status and demographic characteristics and supply-side factors measuring access to physicians. Each group of variables was entered into the model sequentially to assess their explanatory share on regional differences in GP usage.

RESULTS

Both demand-side and supply-side factors were found to influence the frequency of GP visits. Specifically, areas in urban regions, areas with a higher percentage of the population who are obese, who have profound or severe disability, and who hold concession cards, and areas with a smaller percentage of the population who reported difficulty in accessing services have higher GP usage. The availability of more GPs led to higher use of GP services while the supply of more specialists reduced use. 30.56% of the variation was explained by medical need. Together, both need-related and supply-side variables accounted for 32.24% of the regional differences as measured by the standard deviation of adjusted GP-consultation rate.

CONCLUSIONS

There was substantial variation in GP use across Australian regions with only a small proportion of them being explained by population health needs, indicating a high level of unexplained clinical variation. Supply factors did not add a lot to the explanatory power. There was a lot of variation that was not attributable to the factors we could observe. This could be due to more subtle aspects of population need or preferences and therefore warranted. However, it could be due to practice patterns or other aspects of supply and be unexplained. Future work should try to explain the remaining unexplained variation.

The effect of primary care on potentially avoidable hospitalizations in France: a cross-sectional study

Background

Potentially avoidable hospitalizations are an indirect measure of access to primary care. However, the role and quality of primary care might vary by geographical location. The main objective was to assess the impact of primary care on geographic variations of potentially avoidable hospitalizations in Occitanie, France.

Methods

We conducted a retrospective analysis of claims and socio-economic data for the French Occitanie region in 2014. In order to account for spatial heterogeneity, the region was split into two zones based on socio-economic traits: median pre-tax income and unemployment rate. Age- and sex-adjusted hospital discharge potentially avoidable hospitalization rates were calculated at the ZIP-code level. Demographic, socio-economic, and epidemiological determinants were retrieved, as well as data on supply of, access to and utilization of primary care.

Results

72% of PAH are attributable to two chronic conditions: chronic obstructive pulmonary disease and heart failure. In Zone 1, the potentially avoidable hospitalization rate was positively associated with premature mortality and with the number of specialist encounters by patients. It was negatively associated with the density of nurses. In Zone 2, the potentially avoidable hospitalization rate was positively associated with premature mortality, with access to general practitioners, and with the number of nurse encounters by patients. It was negatively associated with the proportion of the population having at least one general practitioner encounter and with the density of nurses.

Conclusions

This study suggests that the role of primary care in potentially avoidable hospitalizations might be geography dependent.

Influence of deprivation on initial severity and prognosis of patients admitted to the ICU: the prospective, multicentre, observational IVOIRE cohort study

Background

The influence of socioeconomic status on patient outcomes is unclear. We assessed the impact of socioeconomic deprivation on severity of illness at intensive care unit (ICU) admission, and on the risk of death at 3 months after ICU admission.

Methods

The IVOIRE study was a prospective, observational, multicentre cohort study in the ICU of 8 participating hospitals in France, including patients aged ≥ 18 years admitted to the ICU and receiving at least one life support therapy for organ failure. The primary outcomes were severity at admission (assessed by SAPSII score), and mortality at 3 months. Socioeconomic data were obtained from interviews with patients or family. Deprivation was assessed using the EPICES score.

Results

Among 1294 patents included between 2013 and 2016, 629 (48.6%) were classed as deprived and differed significantly from non-deprived subjects in terms of sociodemographic characteristics and pre-existing conditions. The mean SAPS II score at admission was 50.1 ± 19.4 in deprived patients and 52.3 ± 17.3 in non-deprived patients, with no significant difference by multivariable analysis (β = − 1.85 [95% CI − 3.86; + 0.16, p = 0.072]). The proportion of death was 31.1% at 3 months, without significant differences between deprived and non-deprived patients, even after adjustment for confounders.

Conclusions

Deprivation is frequent in patients admitted to the ICU and is not associated with disease severity at admission, or with mortality at 3 months between deprived and non-deprived patients.

Trial registration The IVOIRE cohort is registered with ClinicalTrials.gov under the identifier NCT01907581, registration date 17/7/2013

Factors associated with the rates of coronary artery bypass graft and percutaneous coronary intervention

BACKGROUND

Korea has seen a rapid increase in the use of percutaneous coronary intervention (PCI) with the ratio of PCI to coronary artery bypass graft (CABG) the highest in the world. This study was performed to examine the factors associated with the rates of CABG and PCI.

METHODS

The data were acquired from the National Health Insurance database in Korea in 2013. We calculated the age-sex standardized rates of CABG and PCI. We examined the factors associated with the CABG and PCI rates by performing a regression analysis.

RESULTS

The rate of CABG showed a negative association with the deprivation index score, and other factors, such as the number of providers or hospital beds, did not show any significant association with the CABG rate. The rate of PCI had a strong negative association with the number of cardiothoracic surgeons and a strong positive association with the number of hospital beds.

CONCLUSIONS

The positive association between the PCI rate and the number of hospital beds suggests that the use of PCI may be driven by the supply of beds, and the inverse association between the PCI rate and the number of cardiothoracic surgeons indicates the overuse of PCI due to lack of the providers of CABG. Policy measures should be taken to optimize the use of revascularization procedures, the choice of which should primarily be based on the patient's need.

Regional variation of avoidable hospitalisations in a universal health care system: a register-based cohort study from Finland 1996-2013

OBJECTIVES

A persistent finding in research concerning healthcare and hospital use in Western countries has been regional variation in the medical practices. The aim of the current study was to examine trends in the regional variation of avoidable hospitalisations, that is, hospitalisations due to conditions treatable in ambulatory care in Finland in 1996-2013 and the influence of different healthcare levels on them.

SETTING

Use of hospital inpatient care in 1996-2013 among the total population in Finland.

PARTICIPANTS

Altogether 1 931 012 hospital inpatient care episodes among all persons residing in Finland identified from administrative registers in Finland in 1996-2013 and alive in 1 January 1996.

OUTCOME MEASURES

We examined hospitalisations due to avoidable causes including vaccine-preventable hospitalisations, hospitalisations due to complications of chronic conditions and acute conditions treatable in ambulatory care. We calculated annual age-adjusted rates per 10 000 person-years. Multilevel models were used for studying time trends in regional variation.

RESULTS

There was a steep decline in avoidable hospitalisation rates during the study period. The decline occurred almost exclusively in hospitalisations due to chronic conditions, which diminished by about 60%. The overall correlation between hospital district intercepts and slopes in time was -0.46 (p<0.05) among men and -0.20 (ns) among women. Statistically highly significant diminishing variation was found in hospitalisations due to chronic conditions among both men (-0.90) and women (-0.91). The variation was mainly distributed to the hospital district level.

CONCLUSIONS

The results suggest that chronic conditions are managed better in primary care in the whole country than before. Further research is needed on whether this is the case or whether this has more to do with supply of hospital care.

Geographic health inequalities in Norway: a Gini analysis of cross-county differences in mortality from 1980 to 2014

Background

This study aims at quantifying the level and changes over time of inequality in age-specific mortality and life expectancy between the 19 Norwegian counties from 1980 to 2014.

Methods

Data on population and mortality by county was obtained from Statistics Norway for 1980–2014. Life expectancy and age-specific mortality rates (0–4, 5–49 and 50–69 age groups) were estimated by year and county. Geographic inequality was described by the absolute Gini index annually.

Results

Life expectancy in Norway has increased from 75.6 to 82.0 years, and the risk of death before the age of 70 has decreased from 26 to 14% from 1980 to 2014. The absolute Gini index decreased over the period 1980 to 2014 from 0.43 to 0.32 for life expectancy, from 0.012 to 0.0057 for the age group 50–69 years, from 0.0038 to 0.0022 for the age group 5–49 years, and from 0.0009 to 0.0006 for the age group 0–4 years. It will take between 2 and 32 years (national average 7 years) until the counties catch up with the life expectancy in the best performing county if their annual rates of increase remain unchanged.

Conclusion

Using the absolute Gini index as a metric for monitoring changes in geographic inequality over time may be a valuable tool for informing public health policies. The absolute inequality in mortality and life expectancy between Norwegian counties has decreased from 1980 to 2014.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0771-7) contains supplementary material, which is available to authorized users.

Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions

Socioeconomic status (SES) has a measurable and significant effect on cardiovascular health. Biological, behavioral, and psychosocial risk factors prevalent in disadvantaged individuals accentuate the link between SES and cardiovascular disease (CVD). Four measures have been consistently associated with CVD in high-income countries: income level, educational attainment, employment status, and neighborhood socioeconomic factors. In addition, disparities based on sex have been shown in several studies. Interventions targeting patients with low SES have predominantly focused on modification of traditional CVD risk factors. Promising approaches are emerging that can be implemented on an individual, community, or population basis to reduce disparities in outcomes. Structured physical activity has demonstrated effectiveness in low-SES populations, and geomapping may be used to identify targets for large-scale programs. Task shifting, the redistribution of healthcare management from physician to nonphysician providers in an effort to improve access to health care, may have a role in select areas. Integration of SES into the traditional CVD risk prediction models may allow improved management of individuals with high risk, but cultural and regional differences in SES make generalized implementation challenging. Future research is required to better understand the underlying mechanisms of CVD risk that affect individuals of low SES and to determine effective interventions for patients with high risk. We review the current state of knowledge on the impact of SES on the incidence, treatment, and outcomes of CVD in high-income societies and suggest future research directions aimed at the elimination of these adverse factors, and the integration of measures of SES into the customization of cardiovascular treatment.

Do private hospitals outperform public hospitals regarding efficiency, accessibility, and quality of care in the European Union? A literature review

European countries have enhanced the scope of private provision within their health care systems. Privatizing services have been suggested as a means to improve access, quality, and efficiency in health care. This raises questions about the relative performance of private hospitals compared with public hospitals. Most systematic reviews that scrutinize the performance of the private hospitals originate from the United States. A systematic overview for Europe is nonexisting. We fill this gap with a systematic realist review comparing the performance of public hospitals to private hospitals on efficiency, accessibility, and quality of care in the European Union. This review synthesizes evidence from Italy, Germany, the United Kingdom, France, Greece, Austria, Spain, and Portugal. Most evidence suggests that public hospitals are at least as efficient as or are more efficient than private hospitals. Accessibility to broader populations is often a matter of concern in private provision: Patients with higher social-economic backgrounds hold better access to private hospital provision, especially in private parallel systems such as the United Kingdom and Greece. The existing evidence on quality of care is often too diverse to make a conclusive statement. In conclusion, the growth in private hospital provision seems not related to improvements in performance in Europe. Our evidence further suggests that the private (for-profit) hospital sector seems to react more strongly to (financial) incentives than other provider types. In such cases, policymakers either should very carefully develop adequate incentive structures or be hesitant to accommodate the growth of the private hospital sector.

Healthcare-seeking behaviour in case of influenza-like illness in the French general population and factors associated with a GP consultation: an observational prospective study

Background

GP consultation rates for influenza-like illness (ILI) are poorly known in France and there is a paucity of literature on this topic. In the few articles that have been published, the results are heterogeneous.

Aim

The aim of the present study was to estimate the proportion of ILI inducing a GP consultation, and to assess its determinants.

Design & setting

Participants of a French web-based cohort study who reported ≥1 ILI episode between 2012 and 2015 were included. Sociodemographic characteristics, access to health care, and health status variables were collected.

Method

Healthcare-seeking behaviour was analysed and factors associated with a GP consultation identified using a conditional logistic regression.

Results

Of the 6023 ILI episodes reported, 1961 (32.6%) led to a GP consultation, with no difference between those at risk of influenza complications and those not (P = 0.42). A GP consultation was more frequent for individuals living in a rural area (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.02 to 1.43); those with a lower educational level (OR = 1.43, 95% CI = 1.18 to 1.74); those using the internet to find information about influenza (OR = 1.63, 95% CI = 1.30 to 2.03); patients presenting with worrying symptoms (fever, cough, dyspnoea, sputum, or asthenia); patients having a negative perception of their own health status (OR = 1.51, 95% CI = 1.07 to 2.13; and those having declared a personal doctor (OR = 2.86, 95% CI = 1.72 to 4.76). A GP consultation was less frequent for individuals using alternative medicine (OR = 0.68, 95% CI = 0.58 to 0.78).

Conclusion

This study allows the identification of specific factors associated with GP consultation for an ILI episode. These findings may help to coordinate health information campaigns and to raise awareness, especially among individuals at risk of influenza complications.

Regional socioeconomic disparities in outcomes for workers with low back pain in the United States

BACKGROUND

Although regional socioeconomic (SE) factors have been associated with worse health outcomes, prior studies have not addressed important confounders or work disability.

METHODS

A national sample of 59 360 workers' compensation (WC) cases to evaluate impact of regional SE factors on medical costs and length of disability (LOD) in occupational low back pain (LBP).

RESULTS

Lower neighborhood median household incomes (MHI) and higher state unemployment rates were associated with longer LOD. Medical costs were lower in states with more workers receiving Social Security Disability, and in areas with lower MHI, but this varied in magnitude and direction among neighborhoods. Medical costs were higher in more urban, more racially diverse, and lower education neighborhoods.

CONCLUSIONS

Regional SE disparities in medical costs and LOD occur even when health insurance, health care availability, and indemnity benefits are similar. Results suggest opportunities to improve care and disability outcomes through targeted health care and disability interventions.

Geographic variation in potentially avoidable hospitalizations in France

Potentially avoidable hospitalizations are studied as an indirect measure of access to primary care. Understanding the determinants of these hospitalizations can help improve the quality, efficiency, and equity of health care delivery. Few studies have tackled the issue of potentially avoidable hospitalizations in France, and none has done so at the national level. We assessed disparities in potentially avoidable hospitalizations in France in 2012 and analyzed their determinants. The standardized rate of potentially avoidable hospitalizations ranged from 0.1 to 44.4 cases per 1,000 inhabitants, at the ZIP code level. Increased potentially avoidable hospitalizations were associated with higher mortality, lower density of acute care beds and ambulatory care nurses, lower median income, and lower education levels. This study unveils considerable variation in the rate of potentially avoidable hospitalizations in spite of France's mandatory, publicly funded health insurance system. In addition to epidemiological and sociodemographic factors, this study suggests that primary care organization plays a role in geographic disparities in potentially avoidable hospitalizations that might be addressed by increasing the number of nurses and enhancing team work in primary care. Policy makers should consider measuring potentially avoidable hospitalizations in France as an indicator of primary care organization.

The mediation effect of health literacy between subjective social status and depressive symptoms in patients with heart failure

OBJECTIVES

Depressive symptoms are prevalent and cause adverse outcomes in heart failure. Previous studies have linked depressive symptoms with socioeconomic status. However, little is known about the mechanisms underlying this relationship. This study aimed to evaluate the association between socioeconomic status and depressive symptoms, and to examine whether access to healthcare, health literacy and social support mediated this relationship in patients with heart failure.

METHODS

Cross-sectional design was used to study 321 patients with heart failure recruited from a general hospital. Demographics, clinical data, depressive symptoms, socioeconomic status (i.e., education, employment, income, and subjective social status), access to healthcare, health literacy, and social support were collected by patient interview, medical record review or questionnaires. A series of logistic regressions and linear regressions were conducted to examine mediation.

RESULTS

The mean age of patients with heart failure was 63.6±10.6years. Fifty-eight patients (18%) had depressive symptoms. Lower subjective social status (OR=1.321, p=0.012) and lower health literacy (OR=1.065, p<0.001) were separately associated with depressive symptoms. When subjective social status and health literacy were entered simultaneously, the relationship between subjective social status and depressive symptoms became non-significant (OR=1.208, p=0.113), demonstrating mediation. Additionally, lower social support was associated with depressive symptoms (OR=1.062, p=0.007).

CONCLUSIONS

In patients with heart failure, health literacy mediated the relationship between subjective social status and depressive symptoms. Lower social support was associated with depressive symptoms. Interventions should take these factors into account.

Determinants of Regional Variation in Health Expenditures in Germany

Health care expenditure in Germany shows clear regional differences. Such geographic variations are often seen as an indicator for inefficiency. With its homogeneous health care system, low co-payments and uniform prices, Germany is a particularly suited example to analyse regional variations. We use data for the year 2011 on expenditure, utilization of health services and state of health in Germany's statutory health insurance system. This data, which originate from a variety of administrative sources and cover about 90% of the population, are enriched with a wealth of socio-economic variables, data on pollutants, prices and individual preferences. State of health and demography explains 55% of the differences as measured by the standard deviation while all control variables account for a total of 72% of the differences at county level. With other measures of variation, we can account for an even greater proportion. A higher proportion of variation than usually supposed can thus be explained. Whilst this study cannot quantify inefficiencies, our results contradict the thesis that regional variations reflect inefficiency. Copyright © 2015 John Wiley & Sons, Ltd.

Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review

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.

Rates of admission for ambulatory care sensitive conditions in France in 2009-2010: trends, geographic variation, costs, and an international comparison

BACKGROUND

Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume.

METHODS

We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries.

RESULTS

The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients' use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined.

CONCLUSIONS

Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.

Examining regional variation in health care spending in British Columbia, Canada

Examining regional variation in health care spending may reveal opportunities for improved efficiency. Previous research has found that health care spending and service use vary substantially from place to place, and this is often not explained by differences in the health status of populations or by better outcomes in higher-spending regions, but rather by differences in intensity of service provision. Much of this research comes from the United States. Whether similar patterns are observed in other high-income countries is not clear. We use administrative data on health care use, covering the entire population of the Canadian province of British Columbia, to examine how and why health care spending varies among health regions. Pricing and insurance coverage are constant across the population, and we adjust for patient-level age, sex, and recorded diagnoses. Without adjusting for differences in population characteristics, per-capita spending is 50% higher in the highest-spending region than in the lowest. Adjusting for population characteristics as well as the very different environments for health service delivery that exist among metropolitan, non-metropolitan, and remote regions of the province, this falls to 20%. Despite modest variation in total spending, there are marked differences in mortality. In this context, it appears that policy reforms aimed at system-wide quality and efficiency improvement, rather than targeted at high-spending regions, will likely prove most promising.

Comparison of two methods to report potentially avoidable hospitalizations in France in 2012: a cross-sectional study

Background

Potentially avoidable hospitalizations represent an indirect measure of access to effective primary care. However many approaches have been proposed to measure them and results may differ considerably. This work aimed at examining the agreement between the Weissman and Ansari approaches in order to measure potentially avoidable hospitalizations in France.

Methods

Based on the 2012 French national hospital discharge database (Programme de Médicalisation des Systèmes d’Information), potentially avoidable hospitalizations were measured using two approaches proposed by Weissman et al. and by Ansari et al. Age- and sex-standardised rates were calculated in each department. The two approaches were compared for diagnosis groups, type of stay, severity, age, sex, and length of stay.

Results

The number and age-standardised rate of potentially avoidable hospitalizations estimated by the Weissman et al. and Ansari et al. approaches were 742,474 (13.3 cases per 1,000 inhabitants) and 510,206 (9.0 cases per 1,000 inhabitants), respectively. There are significant differences by conditions groups, age, length of stay, severity level, and proportion of medical stays between the Weissman and Ansari methods.

Conclusions

Regarding potentially avoidable hospitalizations in France in 2012, the agreement between the Weissman and Ansari approaches is poor. The method used to measure potentially avoidable hospitalizations is critical, and might influence the assessment of accessibility and performance of primary care.

Applying multivariate clustering techniques to health data: the 4 types of healthcare utilization in the Paris metropolitan area

BACKGROUND

Cost containment policies and the need to satisfy patients' health needs and care expectations provide major challenges to healthcare systems. Identification of homogeneous groups in terms of healthcare utilisation could lead to a better understanding of how to adjust healthcare provision to society and patient needs.

METHODS

This study used data from the third wave of the SIRS cohort study, a representative, population-based, socio-epidemiological study set up in 2005 in the Paris metropolitan area, France. The data were analysed using a cross-sectional design. In 2010, 3000 individuals were interviewed in their homes. Non-conventional multivariate clustering techniques were used to determine homogeneous user groups in data. Multinomial models assessed a wide range of potential associations between user characteristics and their pattern of healthcare utilisation.

RESULTS

We identified four distinct patterns of healthcare use. Patterns of consumption and the socio-demographic characteristics of users differed qualitatively and quantitatively between these four profiles. Extensive and intensive use by older, wealthier and unhealthier people contrasted with narrow and parsimonious use by younger, socially deprived people and immigrants. Rare, intermittent use by young healthy men contrasted with regular targeted use by healthy and wealthy women.

CONCLUSION

The use of an original technique of massive multivariate analysis allowed us to characterise different types of healthcare users, both in terms of resource utilisation and socio-demographic variables. This method would merit replication in different populations and healthcare systems.

Assessment of new public management in health care: the French case

The French health care system embraced New Public Management (NPM) selectively, and crafted their own version of NPM using Diagnostic-Related-Group accounting to re-centralize the health care system. Other organizational changes include the adoption of quasi-markets, public private partnerships, and pay-for-performance schemes for General Practitioners. There is little evidence that these improved the performance of the system. Misrepresentation has remained high. With the 2009 Hospital, Patients, Health and Territories Act physician participation in hospital governance receded. Decision-making powers and health units were re-concentrated to instill greater national coherence into the health system.

Outcomes after first percutaneous coronary intervention for acute myocardial infarction according to patient funding source

Background

Disparities in the use of invasive coronary artery revascularisation procedures to manage acute myocardial infarction (AMI) have been found in several developed economies. Factors such as socio-economic status, income and funding source may influence the use of invasive procedures and have also been associated with ongoing care. The objectives of this study were to determine whether outcomes for patients at one and five years after AMI treated with first-ever percutaneous coronary intervention (PCI) were the same for public and privately funded patients.

Methods

Retrospective, population-based cohort study using linked data to identify 30-day survivors of AMI treated with PCI in the index admission between 1995 and 2008 in Western Australian hospitals. The main outcome measures were admission for another PCI, re-AMI, and all-cause and cardiac mortality at one and five years.

Results

At one year, private patients were at greater adjusted risk for another PCI (HR 1.62 [1.36 – 1.94]; p < 0.001) than public patients, and more likely to have an additional revascularisation procedure from 90 days to 5 years (HR 1.33 [1.11 – 1.58]; p < 0.001). They were at less risk for all-cause death within five years (HR 0.69 [0.62–0.91]; p = 0.01) with a trend to reduced risk for cardiac death and re-AMI.

Conclusions

Treatment as a private patient for AMI with first PCI is associated with an increased likelihood of additional coronary revascularisation procedure within 12 months and to five years, and a reduced risk for all-cause mortality to 5 years. While additional procedures were not associated with poorer outcomes, there was no clear relationship between better outcomes and additional procedures. Other lifestyle and health care factors may contribute to the significant reduction in all-cause mortality and the trends to reduced hazard for AMI and cardiac death among private patients.