High prevalence of forgoing healthcare for economic reasons in Switzerland: a population-based study in a region with universal health insurance coverage

Inequalities in patients' experiences with cancer care: the role of economic and health literacy determinants

BACKGROUND

Patients with fewer socioeconomic and health literacy resources are disadvantaged in their access and use of healthcare, which may give rise to worse experiences with care and thus inequalities in patient experiences. However, only a limited number of studies have examined how socioeconomic and health literacy factors shape inequalities in patients' experiences with cancer care.

OBJECTIVE

To examine whether patients' experiences with cancer care differ according to their economic status and health literacy.

METHODS

Secondary analysis of data on 2789 adult patients diagnosed with cancer from the Swiss Cancer Patient Experiences-2 (SCAPE-2) study, a cross-sectional survey conducted in eight hospitals across Switzerland from September 2021 to February 2022. Regression analysis was applied to examine the independent effect of patients' economic status and health literacy on various outcomes of experiences with cancer care, covering eight different dimensions of patient-centred care, controlling for confounding factors.

RESULTS

Adjusted regression analysis showed that patients with lower economic status reported significantly worse experiences with cancer care in 12 out of 29 specific care experiences, especially in the dimensions of 'respect for patients' preferences' and 'physical comfort' where all items of experiences were associated with economic status. Additionally, lower health literacy was associated with worse patient experiences in 23 specific care experiences. All items in the dimensions of 'respect for patients' preferences', 'physical comfort' and 'emotional support' were associated with health literacy.

DISCUSSION

This study revealed significant inequalities in experiences with cancer care shaped by the economic status and health literacy of patients across different dimensions of patient-centred care. It is essential to address the needs of more disadvantaged patients who face obstacles in their access and use of the healthcare system, not only to mitigate inequalities in cancer care but also to avoid inequalities in health outcomes.

Migrants facing intersectional vulnerability to HIV and AIDS in Switzerland: an exploratory study

An emerging body of evidence suggests that a significant number of HIV-positive migrants to Europe acquire HIV after arriving in their host country. There is an urgent need to rethink HIV and AIDS prevention for migrant populations and to acknowledge the specific vulnerability to HIV and AIDS that migrants face. This article uses empirical data collected in a qualitative sociological study conducted in Switzerland. We provide evidence for the heuristic value of articulating an intersectional approach within a multilevel (biographical, interactional and contextual) framework to capture the complexity of the vulnerability to HIV and AIDS. We show that migrants' specific vulnerability to HIV and AIDS results from social vulnerabilities related to many social and cultural dimensions, including migration status, socioeconomic conditions, gender and sexual identity, sexual norms, the relational context in which sex occurs, power relations and sociocultural structures of the receiving country. The three case studies presented illustrate how HIV-related processes of intersectional vulnerability are embedded in sexism, cisgenderism, and racism, and how they are closely linked to social inequalities in health. Effective HIV and AIDS prevention for migrants must take greater account of these power relations and sociocultural structures.

Universal health coverage in the context of population ageing: catastrophic health expenditure and unmet need for healthcare

BACKGROUND

Universal health coverage means that all people can access essential health services without incurring financial hardship. Even in countries with good service coverage and financial protection, the progress towards universal health coverage may decelerate or be limited with respect to the growing older population. This study investigates the incidence/prevalence, determinants, and consequences of catastrophic health expenditure (CHE) and unmet need for healthcare and assesses the potential heterogeneity between younger (≤ 64 years) and older people (65 years≤).

METHODS

Utilising an annual nationally representative survey of Japanese aged 20 years and over, we estimated the incidence of CHE and unmet need for healthcare using disaggregated estimates by household members' age (i.e. ≤64 years vs. 65 years≤) between 2004 and 2020. Using a fixed-effects model, we assessed the determinants of CHE and unmet need along with the consequences of CHE. We also assessed the heterogeneity by age.

RESULTS

Households with older members were more likely to have their healthcare needs met but experienced CHE more so than households without older members. The financial consequences of CHE were heterogeneous by age, suggesting that households with older members responded to CHE by reducing food and social expenditures more so than households without older members reducing expenditure on education. Households without older members experienced an income decline in the year following the occurrence of CHE, while this was not found among households with older members. A U-shaped relationship was observed between age and the probability of experiencing unmet healthcare need.

CONCLUSIONS

Households with older members are more likely to experience CHE with different financial consequences compared to those with younger members. Unmet need for healthcare is more common among younger and older members than among their middle-aged counterparts. Different types and levels of health and financial support need to be incorporated into national health systems and social protection policies to meet the unique needs of individuals and households.

Drivers for low-acuity pediatric emergency department visits in two tertiary hospitals in Switzerland: a cross-sectional, questionnaire-based study

PURPOSE

Low-acuity pediatric emergency department (PED) visits are frequent in high-income countries and have a negative impact on patient care at the individual and health system levels. Knowing what drives low-acuity PED visits is crucial to inform adaptations in health care delivery. We aimed to identify factors associated with low-acuity PED visits in Switzerland, including socioeconomic status, demographic features, and medical resources of families.

METHODS

We conducted a prospective, questionnaire-based study in the PEDs of two Swiss tertiary care hospitals, Bern and Lausanne. We invited all consecutive children and their caregiver attending the PED during data collection times representative of the overall PED consultation structure (e.g. day/night, weekdays/weekends) to complete a questionnaire on demographic features, socioeconomic status, and medical resources. We collected medical and administrative data about the visit and defined low-acuity visits as those meeting all of the following criteria: (1) triage category 4 or 5 on the Australasian Triage Scale, (2) no imaging or laboratory test performed, and (3) discharge home. We used a binary multiple logistic regression model to identify factors associated with low-acuity visits.

RESULTS

We analysed 778 PED visits (September 2019 to July 2020). Most children visiting our PEDs had a designated primary care provider (92%), with only 6% not having seen them during the last year. Fifty-five per cent of caregivers had asked for medical advice before coming to the PED. The proportion of low-acuity visits was 58%. Low-acuity visits were associated with caregiver's difficulties paying bills (aOR 2.6, 95% CI 1.6 - 4.4), having already visited a PED in the last 6 months (aOR 1.7, 95% CI 1.1 - 2.5) but not with parental education status, nor parental country of birth, parental employment status or absence of family network.

CONCLUSION

Economic precariousness is an important driver for low-acuity PED visits in Switzerland, a high-income country with compulsory health coverage where most children have a designated primary care provider and a regular pediatric follow-up. Primary care providers and PEDs should screen families for economic precariousness and offer anticipatory guidance and connect those in financial need to social support.

Potentially avoidable hospitalizations and socioeconomic status in Switzerland: A small area-level analysis

The Swiss healthcare system is well known for the quality of its healthcare and population health but also for its high cost, particularly regarding out-of-pocket expenses. We conduct the first national study on the association between socioeconomic status and access to community-based ambulatory care (CBAC). We analyze administrative and hospital discharge data at the small area level over a four-year time period (2014 - 2017). We develop a socioeconomic deprivation indicator and rely on a well-accepted indicator of potentially avoidable hospitalizations as a measure of access to CBAC. We estimate socioeconomic gradients at the national and cantonal levels with mixed effects models pooled over four years. We compare gradient estimates among specifications without control variables and those that include control variables for area geography and physician availability. We find that the most deprived area is associated with an excess of 2.80 potentially avoidable hospitalizations per 1,000 population (3.01 with control variables) compared to the least deprived area. We also find significant gradient variation across cantons with a difference of 5.40 (5.54 with control variables) between the smallest and largest canton gradients. Addressing broader social determinants of health, financial barriers to access, and strengthening CBAC services in targeted areas would likely reduce the observed gap.

Socio-demographic and health-related determinants of patients' overall rating and experiences of cancer care

BACKGROUND

Understanding how patient-reported experiences of care and overall rating of care vary among patients with different characteristics is useful to help interpret results from patient experience surveys and design targeted improvement interventions. The primary objective of this paper was to identify the socio-demographic and health-related characteristics independently associated with overall rating of cancer care. The secondary objective was to explore if and how these characteristics were associated with specific experiences of cancer care.

METHODS

This cross-sectional multicenter study analyzed self-reported data collected from 2696 patients diagnosed with breast, prostate, lung, colorectal, skin, or hematological cancer from four large hospitals in French-speaking Switzerland. Multivariate logistic regressions with purposeful stepwise selection of independent variables were used to identify the socio-demographic and health-related characteristics independently associated with overall rating of cancer care in the primary analyses. In the secondary analyses, we ran the multivariate model from the primary analyses with specific experiences of care as outcomes to estimate the adjusted odds ratios (OR) and 95% confidence intervals (CI) of the selected characteristics.

RESULTS

Respondents' mean rating of overall cancer care was 8.5 on a scale from 0 to 10, with 17% categorized as reporting a low rating (0-7 rating). Being a woman (OR 1.43, 95% CI 1.12-1.83), not being Swiss (OR 1.47, 95% CI 1.12-1.94), reporting lower health literacy (OR 1.95, 95% CI 1.54-2.47), preferring making medical decisions alone (OR 1.92, 95% CI 1.38-2.67), having forgone care due to cost (OR 1.72, 95% CI 1.29-2.29), having used complementary medicine (OR 1.55, 95% CI 1.22-1.97), and reporting poorer health (OR 3.12, 95% CI 2.17-4.50) were all independently associated with a low rating of overall cancer care. Poorer health, lower health literacy, and having forgone care were the three characteristics most often associated with problematic experiences of care.

CONCLUSIONS

Our results identified several patient characteristics consistently associated with lower overall rating of care and specific experiences of cancer care. Among these determinants, health literacy and financial hardship emerged as key recurring factors shaping poor patient experiences that should be prioritized for attention by cancer care services.

How socioeconomically disadvantaged people access, understand, appraise, and apply health information: A qualitative study exploring health literacy skills

OBJECTIVES

Health literacy, or a person's competence to access, understand, appraise and apply health information, can be considered a mediating factor between socioeconomic characteristics and health disparities. Socioeconomically disadvantaged people in particular present with less health literacy skills. To develop targeted interventions tailored to their real needs, it is important to understand how they function and what difficulties they encounter when dealing with health information. The purpose of this study was to explore their experiences when accessing, understanding, appraising, and applying health information in their everyday lives.

METHODS

Semi-structured face-to-face interviews were conducted with 12 socioeconomically disadvantaged adults living in the community in Switzerland (age range: 44-60 years old).

RESULTS

Thematic analysis of the interviews yielded four themes, describing the health literacy processes of participants, related barriers, and compensatory strategies used: Financial insecurity triggers the need for health information; Pathway 1: Physicians as ideal (but expensive) interlocutors; Pathway 2: The internet as a suboptimal alternative; and Pathway 3: Relatives as a default resource. The progression of socioeconomically disadvantaged people in the health literacy process is like an 'obstacle course', with numerous steps taken backwards before they can develop compensatory strategies to overcome the barriers to obtaining health information.

CONCLUSIONS

Financial deprivation seems to be the most important factor contributing to health literacy barriers. Appraising health information is the health literacy skill with which socioeconomically disadvantaged people struggle the most. Physician-based, individual skills-based, organizational, and policy-based interventions are needed to help them overcome their health literacy challenges.

A systematic review and meta-analysis of unmet needs for healthcare and long-term care among older people

BACKGROUND

The absolute number of older individuals needing medical care and long-term care (LTC) is increasing globally due to the growing ageing population. However, it is uncertain who and what proportion of the population has access to care. Therefore, a systematic review and meta-analysis of the prevalence and reasons for unmet needs for healthcare and long-term care among older people, 65 years old and above, across countries was conducted.

METHODS

An information specialist performed a comprehensive search of four major databases (PubMed, EMBASE, Web of Science, and CINAHL) from inception to June 2020 without restrictions on language and date. We did random-effects meta-analysis to obtain pooled prevalence. We stratified the meta-analysis by reasons for unmet need categorized by barrier dimension (availability, accessibility, affordability, and acceptability), survey year, geographic location, and socio-demographic characteristics of the older individual.

RESULTS

After screening 3912 articles, we included 101 studies published between 1996 and 2020. Of the 101 studies, 87 studies reported unmet healthcare needs and 14 studies reported unmet LTC needs. Overall, 10.4% (95% CI, 7.3-13.9) of the older population had unmet needs for healthcare. The common reasons for unmet healthcare needs were cost of treatment, lack of health facilities, lack of/conflicting time, health problem not viewed as serious, and mistrust/fear of provider. A significant variation in pooled prevalence of unmet healthcare needs due to cost was found by gender (male [10.9, 95% CI, 8.9-13.1] vs female [14.4, 95% CI, 11.8-17.3]), educational level (primary or less [13.3, 95% CI, 9.6-17.6] vs higher [7.5, 95% CI, 5.9-9.3]), self-reported health (poor [23.2, 95% CI, 18.8-27.8] vs good [4.4, 95% CI, 3.4-5.5]), insurance status (insured [9.0, 95% CI, 7.5-10.6] vs uninsured [27.7, 95% CI, 24.0-31.5]), and economic status of population (poorest [28.2, 95% CI, 14.1-44.9] vs richest [7.1, 95% CI, 3.8-11.3]). One in four (25.1, 95% CI, 17.1-34.2) older people had unmet needs in LTC. Rural residents had a higher prevalence of unmet needs in LTC compared to their urban counterparts.

CONCLUSION

With the population ageing globally, it is necessary to improve access to health care and LTC for older people. Ensuring affordability of health services, reducing geographical barriers, and improving acceptability, will be critical in reducing unmet need. Unmet needs for healthcare were concentrated in population with no education, poor economic group, outpatient health facility user, and uninsured group. With education and economic-based inequalities at the forefront, all countries should focus on improving access to health services by reducing the burden related to healthcare costs.

Life-course socioeconomic conditions and cognitive performance in older adults: a cross-cohort comparison

OBJECTIVES

Socioeconomic disadvantage predicts the level of cognitive performance in old age, but findings have been mixed for trajectories of performance. This study examined associations between life-course socioeconomic conditions, including social mobility, and cognitive performance assessed in terms of level and change, across multiple cognitive domains in two independent cohorts of older adults.

METHODS

Data were from two Swiss population-based cohorts: CoLaus|PsyCoLaus (N = 1210, mean age 72 years) and Vivre/Leben/Vivere (N = 993, mean age 75 years). Verbal fluency, processing speed, cognitive flexibility, memory, and global cognitive performance were assessed at two time points, each spaced 6 years apart. Associations between socioeconomic conditions (father's occupation, parental education, own education, own occupation, household income, and social mobility) and cognitive performance were examined within each cohort, and using pooled data. Covariates included health behaviors, comorbidities, and depressive symptoms.

RESULTS

Across cohorts, socioeconomic disadvantage predicted a lower level of performance across different cognitive domains, including processing speed, verbal fluency, and memory. Moreover, individuals who experienced life-course socioeconomic disadvantage performed worse than those who experienced upward social mobility. Associations between socioeconomic disadvantage and cognitive decline were less consistent.

CONCLUSION

Life-course socioeconomic conditions predict performance level across different cognitive domains, and, to a lesser extent, performance trajectories.

Does the socioeconomic status predict health service utilization in persons with enhanced health care needs? Results from a population-based survey in persons with spinal cord lesions from Switzerland

Background

Evidence suggests that the socioeconomic status (SES) affects individuals’ health service utilization. Spinal cord injury is a condition that often leads to physical impairments and enhanced health care needs. It therefore presents an informative and yet under-researched case in point to investigate social inequalities in health service utilization. This study aims to describe associations between SES and health service utilization in adults with spinal cord injury from Switzerland.

Methods

We use cross-sectional data from 1,294 participants of the Swiss Spinal Cord Injury Cohort Study community survey 2017. SES was operationalized with education, household income, perceived financial hardship, subjective status, and granting of supplementary financial benefits. Health service utilization was assessed with information on visits to 13 different health care providers and four health care institutions (inpatient stays, outpatient clinics, emergency departments, specialized spinal cord centers) during the past 12 months. The dichotomized outcomes on service utilization (visited vs. not visited) were regressed on SES indicators, including adjustments for sociodemographics, lesion characteristics, and health status.

Results

Persons with higher SES reported higher likelihood for specialist, dentist, and dental hygienist visits and reported utilizing a larger number of different care providers. Further, specific SES indicators were associated with certain care provider visits (i.e., higher education and subjective status: higher odds for pharmacist visits; higher income: higher odds for natural healer visits; higher subjective status: higher odds for chiropractor visits; supplementary benefit granting: higher odds for general practitioner and home care service visits). We found statistically non-significant trends towards lower likelihood for inpatient stays, outpatient clinic and emergency department visits and enhanced likelihood for specialized spinal cord-center visits in higher SES groups.

Conclusions

This study generally supports the claim that basic health care provision is guaranteed for all patients with spinal cord injury in Switzerland, independently of their SES. However, social inequalities were still observed for the utilization of specific providers, such as oral health care providers. Given that oral health is key for health maintenance in persons with spinal cord injury, specific interventions to enhance regular dental check-ups in lower SES groups are highly recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01693-6.

Gender inequality and mammography screening: Does living with a partner improve women's mammography uptake?

Macrolevel gender inequality is defined as the unequal distribution of power and resources between men and women shaped by macrolevel social structures and institutions. An emerging line of health research is emphasising its negative consequences on women's health and healthcare access. The present study examines how gender inequality contexts affect women's mammography screening uptake. It adopts a macrosociological and institutionalist approach on preventive healthcare use and compares women who live with a partner with those who do not. This is the first study to test the effect of macrolevel gender inequality on mammography uptake across the 26 Swiss cantons (i.e. regions). The Swiss cantons' autonomy to manage their political and healthcare systems, as provided by the federal system, offers an ideal setting for the comparative analysis of macrolevel factors. Data on 9724 women aged 50-70 from the Swiss Health Interview Survey (waves 2007, 2012 and 2017) is analysed. Multilevel logistic models estimate two canton-level indicators of gender inequality, the gender gaps in time use and full-time employment, and their association with mammography uptake, controlling for women's socioeconomic and demographic characteristics, health status and healthcare use. Cross-level interactions assess how these indicators moderate the mammography uptake of women living with and without a partner. Results show that in cantons with higher gender inequality, women have a lower probability of mammography uptake. Women who live with a partner have a higher mammography uptake than those who do not. However, this advantage is moderated by canton-level gender inequality, namely, women who live with a partner in more gender unequal cantons have a lower mammography uptake than their counterparts who reside in more gender equal cantons. Results support the hypothesis that macrolevel gender inequality moderates women's preventive healthcare uptake, from an institutionalist approach.

Forgoing healthcare during the COVID-19 pandemic in Geneva, Switzerland - A cross-sectional population-based study

BACKGROUND

Health systems around the world continue to navigate through operational challenges surfaced by the coronavirus disease 2019 (COVID-19) pandemic; these have implications for access to healthcare. In this study, we estimate the prevalence and reasons for forgoing healthcare during the pandemic in Geneva, Switzerland; a country with a universal and mandatory private health insurance coverage.

METHODS

Participants from a randomly selected population-based sample of the adult population living in the Canton of Geneva completed an online socio-demographic and lifestyle questionnaire between November 2020 and January 2021. The prevalence and reasons for forgoing healthcare since the beginning of the COVID-19 pandemic were examined descriptively, and logistic regression models were used to assess determinants for forgoing healthcare.

RESULTS

The study included 5397 participants, among which 8.0% reported having forgone healthcare since the beginning of the COVID-19 pandemic; participants with a disadvantaged financial situation (OR = 2.04; 95% CI: 1.56-2.65), and those reporting an average (OR = 2.54; 95% CI: 1.94-3.31) or poor health (OR = 4.40; 95% CI: 2.39-7.67) were more likely to forgo healthcare. The most common reasons to forgo healthcare were appointment cancellations by healthcare providers (53.9%), fear of infection (35.3%), and personal organizational issues (11.1%).

CONCLUSION

Our paper highlights the effects of the COVID-19 pandemic on access to healthcare and identifies population sub-groups at-risk for forgoing healthcare. These results necessitate public health efforts to ensure equitable and accessible healthcare as the COVID-19 pandemic continues.

Revisiting the Effects of Organized Mammography Programs on Inequalities in Breast Screening Uptake: A Multilevel Analysis of Nationwide Data From 1997 to 2017

This study revisits the effects of mammography screening programs on inequalities in breast screening uptake in Switzerland. The progressive introduction of regional mammography programs by 12 out of the 26 Swiss cantons (regions) since 1999 offers an opportunity to perform an ecological quasi-experimental study. We examine absolute income and marital status inequalities in mammography uptake, and whether the cantons' implementation of mammography programs moderate these inequalities, as previous research has devoted little attention to this. We use five waves of the Swiss Health Interview Survey covering the 1997–2017 period and comprising data on 14,267 women aged 50–70. Both up-to-date and ever-screening outcomes are analyzed with multilevel models which assess the mammography programs' within-canton effect. Findings show that higher income women and married women (compared to unmarried women) had significantly higher mammography uptake probabilities. Mammography programs did not moderate absolute income differences in up-to-date screening; however, they were associated with smaller absolute income differences in ever-screening uptake. Mammography programs related to higher screening uptake for married women, more than for unmarried women. In conclusion, we showed absolute income inequalities in mammography uptake which were not revealed by previous studies using relative inequality measures. Mammography programs may have contributed to reducing income inequalities in ever-screening, yet this was not observed for up-to-date screening. This study has implication for preventive health interventions—e.g., cancer screening promotion should pay attention to women's marital status since screening programs may widen the screening gap between married and unmarried women.

Seroprevalence of anti-SARS-CoV-2 IgG antibodies, risk factors for infection and associated symptoms in Geneva, Switzerland: a population-based study

Aims: To assess SARS-CoV-2 seroprevalence over the first epidemic wave in the canton of Geneva, Switzerland, as well as risk factors for infection and symptoms associated with IgG seropositivity. Methods: Between April and June 2020, former participants of a representative survey of the 20-74-year-old population of canton Geneva were invited to participate in the study, along with household members aged over 5 years. Blood samples were tested for anti-SARS-CoV-2 immunoglobulin G. Questionnaires were self-administered. We estimated seroprevalence with a Bayesian model accounting for test performance and sampling design. Results: We included 8344 participants, with an overall adjusted seroprevalence of 7.8% (95% credible interval 6.8-8.9). Seroprevalence was highest among 18-49 year-olds (9.5%), and lowest in 5-9-year-old children (4.3%) and individuals >65 years (4.7-5.4%). Odds of seropositivity were significantly reduced for female retirees and unemployed men compared to employed individuals, and smokers compared to non-smokers. We found no significant association between occupation, level of education, neighborhood income and the risk of being seropositive. The symptom most strongly associated with seropositivity was anosmia/dysgeusia. Conclusions: Anti-SARS-CoV-2 population seroprevalence remained low after the first wave in Geneva. Socioeconomic factors were not associated with seropositivity in this sample. The elderly, young children and smokers were less frequently seropositive, although it is not clear how biology and behaviours shape these differences.

Prevalence and characterization of forgoing care: comparison of two prospective multicentre cohorts between pre-COVID-19 era and a lockdown period

BACKGROUND

Little is known about patients who forego healthcare, although it is an important provider of unfavorable health-related outcomes. Forgoing healthcare characterizes situations in which people do not initiate or interrupt a care process, even though they perceive the need for it, whether or not this need is medically proven. The aims of this study were to assess the prevalence and the determinants of patients who forego healthcare. The second aim was to compare the characteristics of patients who gave up healthcare during the French lockdown due to COVID-19.

METHODS

We conducted two multicenter cross-sectional studies in 2017 and 2020 carried out in French patients presenting to the emergency departments. Patients who gave their consent to participate were interviewed with a standardized questionnaire. It consisted of two parts: epidemiological characteristics and health care refusal. A third part concerning the renunciation of care during the COVID-19 period was added to the second study period.

RESULTS

A total of 1878 patients had completed the questionnaire during the interview with the physicians, 900 during the first period in 2017 (47.9%) and 978 (52.1%) during the second period. A total of 401/1878 patients reported not seeking care in the last 12 months (21.4% [95%CI: 19.5-23.3%]). In 2020, patients forewent care more during the confinement period than outside with different characteristics of the foregoing care populations.

CONCLUSION

Forgoing care is common in a universal health care system such as France's and increased during the pandemic. Key public health messages targeted at the reasons for not seeking care must now be disseminated in order to combat this.

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.

Socioeconomic position and the COVID-19 care cascade from testing to mortality in Switzerland: a population-based analysis

BACKGROUND

The inverse care law states that disadvantaged populations need more health care than advantaged populations but receive less. Gaps in COVID-19-related health care and infection control are not well understood. We aimed to examine inequalities in health in the care cascade from testing for SARS-CoV-2 to COVID-19-related hospitalisation, intensive care unit (ICU) admission, and death in Switzerland, a wealthy country strongly affected by the pandemic.

METHODS

We analysed surveillance data reported to the Swiss Federal Office of Public Health from March 1, 2020, to April 16, 2021, and 2018 population data. We geocoded residential addresses of notifications to identify the Swiss neighbourhood index of socioeconomic position (Swiss-SEP). The index describes 1·27 million small neighbourhoods of approximately 50 households each on the basis of rent per m2, education and occupation of household heads, and crowding. We used negative binomial regression models to calculate incidence rate ratios (IRRs) with 95% credible intervals (CrIs) of the association between ten groups of the Swiss-SEP index defined by deciles (1=lowest, 10=highest) and outcomes. Models were adjusted for sex, age, canton, and wave of the epidemic (before or after June 8, 2020). We used three different denominators: the general population, the number of tests, and the number of positive tests.

FINDINGS

Analyses were based on 4 129 636 tests, 609 782 positive tests, 26 143 hospitalisations, 2432 ICU admissions, 9383 deaths, and 8 221 406 residents. Comparing the highest with the lowest Swiss-SEP group and using the general population as the denominator, more tests were done among people living in neighbourhoods of highest SEP compared with lowest SEP (adjusted IRR 1·18 [95% CrI 1·02-1·36]). Among tested people, test positivity was lower (0·75 [0·69-0·81]) in neighbourhoods of highest SEP than of lowest SEP. Among people testing positive, the adjusted IRR was 0·68 (0·62-0·74) for hospitalisation, was 0·54 (0·43-0·70) for ICU admission, and 0·86 (0·76-0·99) for death. The associations between neighbourhood SEP and outcomes were stronger in younger age groups and we found heterogeneity between areas.

INTERPRETATION

The inverse care law and socioeconomic inequalities were evident in Switzerland during the COVID-19 epidemic. People living in neighbourhoods of low SEP were less likely to be tested but more likely to test positive, be admitted to hospital, or die, compared with those in areas of high SEP. It is essential to continue to monitor testing for SARS-CoV-2, access and uptake of COVID-19 vaccination and outcomes of COVID-19. Governments and health-care systems should address this pandemic of inequality by taking measures to reduce health inequalities in response to the SARS-CoV-2 pandemic.

FUNDING

Swiss Federal Office of Public Health, Swiss National Science Foundation, EU Horizon 2020, Branco Weiss Foundation.

Vulnerable patients forgo health care during the first wave of the Covid-19 pandemic

During the first wave of the Covid-19 pandemic, access to health care was limited, and patients encountered important delays for scheduled appointments and care. Empirical data relying on patients' reports of forgoing health care are scarce. This study investigated Covid-19-related self-reports of forgoing health care in a sample of vulnerable outpatients in Geneva, Switzerland. We collected data from 1167 adult outpatients, including clinically vulnerable patients (with chronic diseases), geriatric patients (involved in a health care network for people aged 60 or older), and socially vulnerable patients (involved in a migrant health program or a mobile outpatient community care center) in June 2020. Data on sociodemographic factors, forgoing health care, and anti-SARS-CoV-2 antibodies were collected. Of the patients, 38.5% reported forgoing health care. Forgoing health care was more frequent for younger patients, women, patients with a low level of education, and patients with a chronic disease (p < .001). There was no significant association between the presence of anti-SARS-CoV-2 antibodies and forgoing health care (p = .983). As the decrease in routine management of patients might have important and unpredictable adverse health consequences, avoiding delayed health care is crucial.

Health Insurance Deductibles and Health Care-Seeking Behaviors in a Consumer-Driven Health Care System With Universal Coverage

IMPORTANCE

Characteristics of a health care system can facilitate forgoing of health care owing to economic reasons and can influence population health. Whether health insurance deductibles are associated with forgoing of health care in a consumer-driven health care system with universal coverage, such as the Swiss health system, remains to be determined.

OBJECTIVE

To assess the association between insurance plan deductibles and forgoing of health care with consideration of socioeconomic factors.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted in Geneva, Switzerland, using data collected from January 1, 2007, to December 31, 2019. Population-based samples were obtained yearly through random stratified sampling by age and sex of the general population aged 20 to 74 years. Participants were invited to an appointment at 1 of the 3 study sites in Geneva, where they completed a sociodemographic and health questionnaire.

EXPOSURES

Insurance plan deductible level.

MAIN OUTCOMES AND MEASURES

The main outcome was forgoing of health care owing to economic reasons. Unadjusted and multivariable Poisson models were used to assess the association between deductible level and forgoing of health care. Differences in forgoing health care across the range of health insurance deductibles or household income levels were quantified using the relative index of inequality (RII).

RESULTS

The study group included 11 872 participants (5974 [50.3%] male; median age, 48.1 years [interquartile range, 38.7-59.1 years]); 1146 (9.7%) reported forgoing health care. Participants with high-deductible plans reported forgoing health care more frequently than those with low-deductible plans (331 [13.5%] vs 591 [8.7%]). In adjusted analysis, higher-deductible plans were associated with a greater likelihood of forgoing health care (RII, 2.2; 95% CI, 1.7-3.0; P < .001) independently of socioeconomic status, known comorbidities, and cardiovascular risk factors. Deductible level was associated with forgoing of health care among participants younger than 40 years (RII, 2.5; 95% CI, 1.6-4.0; P < .001) and those aged 40 to 64 years (RII, 1.9; 95% CI, 1.3-2.9; P = .002) but not among those older than 65 years (RII, 2.9; 95% CI, 0.8-10.4; P = .11).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, high insurance plan deductibles were associated with forgoing of health care independent of socioeconomic status and preexisting conditions in a universal consumer-driven health care system with good population outcomes in Switzerland. Uncovering health care system design features that could lead to suboptimal population care may help decision makers improve their current health care system design to achieve better outcomes.

Macro-contextual determinants of cancer screening participation and inequalities: A multilevel analysis of 29 European countries

Background

Little attention has been devoted to the role of macro-level determinants in preventive health inequalities, particularly in cancer screening participation. Research has evidenced inequalities in cancer screening uptake yet has mainly focused on the screening programmes’ moderating role at the macro-level. To address this gap, this study examines how welfare provision and healthcare system features modify cancer screening uptake and inequalities across European countries.

Methods

Data from 99 715 (Pap smear) and 54 557 (mammography) women in 29 countries from the European Health Interview Survey (EHIS) 2014 wave and Swiss Health Interview Survey (SHIS) 2012 wave was analysed. We estimated multilevel logistic regression models, including cross-level interactions, to examine whether social protection expenditure in particular policy areas and healthcare system characteristics explained cross-country differences in Pap smear and mammography uptake and inequalities.

Results

Main findings revealed that GP gatekeeping systems were associated with reduced screening uptake likelihood in both Pap smear and mammography, and so were stronger primary care systems in Pap smear, while higher expenditures on old age and survivors were associated with increased mammography uptake. Cross-level interactions showed that in countries with higher expenditures on sickness/healthcare, disability, social exclusion and public health, and a higher number of GPs, educational inequalities in both Pap smear and mammography uptake were smaller, while higher out-of-pocket payments had the opposite effect of increasing inequalities.

Conclusions

Overall, our results show that social protection policies and healthcare system features affect cancer screening participation. We conclude that institutional and policy arrangements interact with individuals’ (educational) resources and, through the (re)distribution of valued goods and resources at the macro level, these arrangements may contribute to enhancing preventive healthcare use and mitigating screening uptake inequalities.

•

Welfare provision and healthcare system features affect Pap smear and mammography uptake.

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Social spending and healthcare features moderate inequalities in cancer screening uptake.

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Policymakers should consider macro-level factors for cancer screening strategies and programmes.

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Policies and institutions shape social determinants of preventive healthcare use.

Degree of regional variation and effects of health insurance-related factors on the utilization of 24 diverse healthcare services - a cross-sectional study

Background

Regional variation in healthcare utilization could reflect unequal access to care, which may lead to detrimental consequences to quality of care and costs. The aims of this study were to a) describe the degree of regional variation in utilization of 24 diverse healthcare services in eligible populations in Switzerland, and b) identify potential drivers, especially health insurance-related factors, and explore the consistency of their effects across the services.

Methods

We conducted a cross-sectional study using health insurance claims data for the year of 2014. The studied 24 healthcare services were predominantly outpatient services, ranging from screening to secondary prevention. For each service, a target population was identified based on applicable clinical recommendations, and outcome variable was the use of the service. Possible influencing factors included patients’ socio-demographics, health insurance-related and clinical characteristics. For each service, we performed a comprehensive methodological approach including small area variation analysis, spatial autocorrelation analysis, and multilevel multivariable modelling using 106 mobilité spaciale regions as the higher level. We further calculated the median odds ratio in model residuals to assess the unexplained regional variation.

Results

Unadjusted utilization rates varied considerably across the 24 healthcare services, ranging from 3.5% (osteoporosis screening) to 76.1% (recommended thyroid disease screening sequence). The effects of health insurance-related characteristics were mostly consistent. A higher annual deductible level was mostly associated with lower utilization. Supplementary insurance, supplementary hospital insurance and having chosen a managed care model were associated with higher utilization of most services. Managed care models showed a tendency towards more recommended care. After adjusting for multiple influencing factors, the unexplained regional variation was generally small across the 24 services, with all MORs below 1.5.

Conclusions

The observed utilization rates seemed suboptimal for many of the selected services. For all of them, the unexplained regional variation was relatively small. Our findings confirmed the importance and consistency of effects of health insurance-related factors, indicating that healthcare utilization might be further optimized through adjustment of insurance scheme designs. Our comprehensive approach aids in the identification of regional variation and influencing factors of healthcare services use in Switzerland as well as comparable settings worldwide.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05930-y.

Never and under cervical cancer screening in Switzerland and Belgium: trends and inequalities

Background

Research on inequalities in cervical cancer screening (CCS) participation has overlooked the distinction between ‘never-’ and ‘under-screeners’ while different socioeconomic and demographic determinants may underlie ‘non-’ and ‘under-’ screening participation. This study examines socioeconomic and demographic inequalities in never and under CCS participation. We compare cross-national prevalence and trends among these two groups in Switzerland and Belgium, two countries with similar opportunistic CCS strategy but different healthcare systems.

Methods

Data on 38,806 women aged 20–70 from the Swiss Health Interview Survey (1992–2012) and 19,019 women aged 25–64 from the Belgian Health Interview Survey (1997–2013), both population-based cross-sectional nationally representative surveys, was analysed. Weighted adjusted prevalence ratios were estimated with multivariate Poisson regressions.

Results

Over the studied period, never screening prevalence was about 15% in both Switzerland and Belgium and under screening prevalence about 14.0%. Socioeconomic gradients were found among both never- and under-screeners. Higher income women had lower never and under screening prevalence in Switzerland and a similar gradient in education was observed in Belgium. Importantly, distinct socioeconomic and demographic determinants were found to underlie never and under screening participation. Never screening was significantly higher among foreign nationals in both countries and this association was not observed in under screening. Never screening prevalence was lower among older age groups, while under screening increased with older age. Over time, age inequalities diminished among never- and under- screeners in Switzerland while educational inequalities increased among never-screeners in Belgium.

Conclusion

Findings revealed that determinants of screening inequalities differed among never- and under-screeners and hence these should be addressed with different public health strategies. Crucially, socioeconomic and demographic inequalities were more pronounced among never-screeners who appeared to face more structural and persistent inequalities. Differences between the two countries should also be noted. The more liberal-type Swiss healthcare systems appeared to shape income-related screening inequalities, while education appeared to be a stronger determinant of never- and under-screening in Belgium.

Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a population-based study

BACKGROUND

Assessing the burden of COVID-19 on the basis of medically attended case numbers is suboptimal given its reliance on testing strategy, changing case definitions, and disease presentation. Population-based serosurveys measuring anti-severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2) antibodies provide one method for estimating infection rates and monitoring the progression of the epidemic. Here, we estimate weekly seroprevalence of anti-SARS-CoV-2 antibodies in the population of Geneva, Switzerland, during the epidemic.

METHODS

The SEROCoV-POP study is a population-based study of former participants of the Bus Santé study and their household members. We planned a series of 12 consecutive weekly serosurveys among randomly selected participants from a previous population-representative survey, and their household members aged 5 years and older. We tested each participant for anti-SARS-CoV-2-IgG antibodies using a commercially available ELISA. We estimated seroprevalence using a Bayesian logistic regression model taking into account test performance and adjusting for the age and sex of Geneva's population. Here we present results from the first 5 weeks of the study.

FINDINGS

Between April 6 and May 9, 2020, we enrolled 2766 participants from 1339 households, with a demographic distribution similar to that of the canton of Geneva. In the first week, we estimated a seroprevalence of 4·8% (95% CI 2·4-8·0, n=341). The estimate increased to 8·5% (5·9-11·4, n=469) in the second week, to 10·9% (7·9-14·4, n=577) in the third week, 6·6% (4·3-9·4, n=604) in the fourth week, and 10·8% (8·2-13·9, n=775) in the fifth week. Individuals aged 5-9 years (relative risk [RR] 0·32 [95% CI 0·11-0·63]) and those older than 65 years (RR 0·50 [0·28-0·78]) had a significantly lower risk of being seropositive than those aged 20-49 years. After accounting for the time to seroconversion, we estimated that for every reported confirmed case, there were 11·6 infections in the community.

INTERPRETATION

These results suggest that most of the population of Geneva remained uninfected during this wave of the pandemic, despite the high prevalence of COVID-19 in the region (5000 reported clinical cases over <2·5 months in the population of half a million people). Assuming that the presence of IgG antibodies is associated with immunity, these results highlight that the epidemic is far from coming to an end by means of fewer susceptible people in the population. Further, a significantly lower seroprevalence was observed for children aged 5-9 years and adults older than 65 years, compared with those aged 10-64 years. These results will inform countries considering the easing of restrictions aimed at curbing transmission.

FUNDING

Swiss Federal Office of Public Health, Swiss School of Public Health (Corona Immunitas research program), Fondation de Bienfaisance du Groupe Pictet, Fondation Ancrage, Fondation Privée des Hôpitaux Universitaires de Genève, and Center for Emerging Viral Diseases.

Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a population-based study

BACKGROUND

Assessing the burden of COVID-19 on the basis of medically attended case numbers is suboptimal given its reliance on testing strategy, changing case definitions, and disease presentation. Population-based serosurveys measuring anti-severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2) antibodies provide one method for estimating infection rates and monitoring the progression of the epidemic. Here, we estimate weekly seroprevalence of anti-SARS-CoV-2 antibodies in the population of Geneva, Switzerland, during the epidemic.

METHODS

The SEROCoV-POP study is a population-based study of former participants of the Bus Santé study and their household members. We planned a series of 12 consecutive weekly serosurveys among randomly selected participants from a previous population-representative survey, and their household members aged 5 years and older. We tested each participant for anti-SARS-CoV-2-IgG antibodies using a commercially available ELISA. We estimated seroprevalence using a Bayesian logistic regression model taking into account test performance and adjusting for the age and sex of Geneva's population. Here we present results from the first 5 weeks of the study.

FINDINGS

Between April 6 and May 9, 2020, we enrolled 2766 participants from 1339 households, with a demographic distribution similar to that of the canton of Geneva. In the first week, we estimated a seroprevalence of 4·8% (95% CI 2·4-8·0, n=341). The estimate increased to 8·5% (5·9-11·4, n=469) in the second week, to 10·9% (7·9-14·4, n=577) in the third week, 6·6% (4·3-9·4, n=604) in the fourth week, and 10·8% (8·2-13·9, n=775) in the fifth week. Individuals aged 5-9 years (relative risk [RR] 0·32 [95% CI 0·11-0·63]) and those older than 65 years (RR 0·50 [0·28-0·78]) had a significantly lower risk of being seropositive than those aged 20-49 years. After accounting for the time to seroconversion, we estimated that for every reported confirmed case, there were 11·6 infections in the community.

INTERPRETATION

These results suggest that most of the population of Geneva remained uninfected during this wave of the pandemic, despite the high prevalence of COVID-19 in the region (5000 reported clinical cases over <2·5 months in the population of half a million people). Assuming that the presence of IgG antibodies is associated with immunity, these results highlight that the epidemic is far from coming to an end by means of fewer susceptible people in the population. Further, a significantly lower seroprevalence was observed for children aged 5-9 years and adults older than 65 years, compared with those aged 10-64 years. These results will inform countries considering the easing of restrictions aimed at curbing transmission.

FUNDING

Swiss Federal Office of Public Health, Swiss School of Public Health (Corona Immunitas research program), Fondation de Bienfaisance du Groupe Pictet, Fondation Ancrage, Fondation Privée des Hôpitaux Universitaires de Genève, and Center for Emerging Viral Diseases.

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.

The challenge of implementing Less is More medicine: A European perspective

The concept of Less is More medicine emerged in North America in 2010. It aims to serve as an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health, tackling the erroneous assumption that more care is always better. In response, several medical societies across the world launched quality-driven campaigns ("Choosing Wisely") and published "top-five lists" of low-value medical interventions that should be used to help make wise decisions in each clinical domain, by engaging patients in conversations about unnecessary tests, treatments and procedures. However, barriers and challenges for the implementation of Less is More medicine have been identified in several European countries, where overuse is rooted in the culture and demanded by a society that requests certainty at almost any cost. Patients' high expectations, physician's behavior, lack of monitoring and pernicious financial incentives have all indirect negative consequences for medical overuse. Multiple interventions and quality-measurement efforts are necessary to widely implement Less is More recommendations. These also consist of a top-five list of actions: (1) a novel cultural approach starting from medical graduation courses, up to (2) patient and society education, (3) physician behavior change with data feedback, (4) communication training and (5) policy maker interventions. In contrast with the prevailing maximization of care, the optimization of care promoted by Less is More medicine can be an intellectual challenge but also a real opportunity to promote sustainable medicine. This project will constitute part of the future agenda of the European Federation of Internal Medicine.

Variation of colorectal, breast and prostate cancer screening activity in Switzerland: Influence of insurance, policy and guidelines

Variation in utilization of healthcare services is influenced by patient, provider and healthcare system characteristics. It could also be related to the evidence supporting their use, as reflected in the availability and strength of recommendations in clinical guidelines. In this study, we analyzed the geographic variation of colorectal, breast and prostate cancer screening utilization in Switzerland and the influence of available guidelines and different modifiers of access. Colonoscopy, mammography and prostate specific antigen (PSA) testing use in eligible population in 2014 was assessed with administrative claims data. We ran a multilevel multivariable logistic regression model and calculated Moran's I and regional level median odds ratio (MOR) statistics to explore residual geographic variation. In total, an estimated 8.1% of eligible persons received colonoscopy, 22.3% mammography and 31.3% PSA testing. Low deductibles, supplementary health insurance and enrollment in a managed care plan were associated with higher screening utilization. Cantonal breast cancer screening programs were also associated with higher utilization. Spatial clustering was observed in the raw regional utilization of all services, but only for prostate cancer screening in regional residuals of the multilevel model. MOR was highest for prostate cancer screening (1.24) and lowest for colorectal cancer screening (1.16). The reasons for the variation of the prostate cancer screening utilization, not recommended routinely without explicit shared decision-making, could be further investigated by adding provider characteristics and patient preference information. This first cross-comparison of different cancer screening patterns indicates that the strength of recommendations, mediated by specific health policies facilitating screening, may indeed contribute to variation.

Exploring geographic variation of and influencing factors for utilization of four diabetes management measures in Swiss population using claims data

INTRODUCTION

Four strongly recommended diabetes management measures are biannual glycated hemoglobin (HbA1c) testing, annual eye examination, kidney function examination, and low-density lipoprotein (LDL) testing in patients below 75 years. We aimed to describe regional variation in the utilization of the four measures across small regions in Switzerland and to explore potential influencing factors.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional study of adult patients with drug-treated diabetes in 2014 using claims data. Four binary outcomes represented adherence to the recommendations. Possible influencing factors included sociodemographics, health insurance preferences, and clinical characteristics. We performed multilevel modeling with Medstat regions as the higher level. We calculated the median odds ratio (MOR) and checked spatial autocorrelation in region level residuals using Moran's I statistic. When significant, we further conducted spatial multilevel modeling.

RESULTS

Of 49 198 patients with diabetes (33 957 below 75 years), 69.6% had biannual HbA1c testing, 44.3% each had annual eye examination and kidney function examination, and 55.5% of the patients below 75 years had annual LDL testing. The effects of health insurance preferences were substantial and consistent. Having any supplementary insurance (ORs across measures were between 1.08 and 1.28), having supplementary hospital care insurance (1.08-1.30), having chosen a lower deductible level (eg, SFr2500 compared with SFr300: 0.57-0.69), and having chosen a managed care model (1.04-1.17) were positively associated with recommendations adherence. The MORs (1.27-1.33) showed only moderate unexplained variation, and we observed inconsistent spatial patterns of unexplained variation across the four measures.

CONCLUSION

Our findings indicate that the uptake of strongly recommended measures in diabetes management could possibly be optimized by providing further incentives to patients and care providers through insurance scheme design. The absence of marked regional variation implies limited potential for improvement by targeted regional intervention, while provider-specific promotion may be more impactful.

Households forgoing healthcare as a measure of financial risk protection: an application to Liberia

INTRODUCTION

Access to Liberia's health system is reliant on out-of-pocket (OOP) health expenditures which may prevent people from seeking care or result in catastrophic health expenditure (CHE). CHE and impoverishment due to OOP, which are used by the World Bank and World Health Organization as the sole measures of financial risk protection, are limited: they do not consider households who, following a health shock, do not incur expenditure because they cannot access the healthcare services they need (i.e., households forgoing healthcare (HFH) services). This paper attempts to overcome this limitation and improve financial risk protection by measuring HFH incidence and comparing it with CHE standard measures using household survey data from Liberia.

METHODS

Data from the Liberia Household Income and Expenditure Survey 2014 were analysed. An OOP health expenditure is catastrophic when it exceeds a total or non-food household expenditure threshold. A CHE incidence curve, representing CHE incidence at different thresholds, was developed. To overcome CHE limitations, an HFH incidence measure was developed based on CHE, OOP and health shocks data: households incurring health shocks and having negligible OOP were considered to have forgone healthcare. HFH incidence was compared with standard CHE measures.

RESULTS

CHE incidence and intensity levels depend on the threshold used. Using a 30% non-food expenditure threshold, CHE incidence is 2.1% (95% CI: 1.7-2.5%) and CHE intensity is 37.4% (95% CI: 22.7-52.0%). CHE incidence is approximately in line with other countries, while CHE intensity is higher than in other countries. CHE pushed 1.6% of households below the food poverty line in 2014. c approximately 4 times higher than CHE (8.0, 95% CI, 7.2-8.9%).

CONCLUSION

Lack of financial risk protection is a significant problem in Liberia and it may be underestimated by CHE: this study confirms that HFH incidence can complement CHE measures in providing a complete picture of financial risk protection and demonstrates a simple method that includes measures of healthcare forgone as part of standard CHE analyses. This paper provides a new methodology to measure HFH incidence and highlights the need to consider healthcare forgone in analyses of financial risk protection, as well as the need for further development of these measures.

Skin cancer screening in Switzerland: Cross-sectional trends (1997-2012) in socioeconomic inequalities

INTRODUCTION

Skin cancer is one of the most common malignancies. Despite controversy over its efficacy, skin cancer screening has become widespread although socioeconomic screening inequalities have been documented. Switzerland has the highest rate of melanoma in Europe but Swiss trends in skin cancer screening and social disparities have not been investigated. This study aims to evaluate trends in skin cancer screening and its association with socioeconomic indicators in Switzerland between 1997 and 2012.

METHOD

We used data from four waves (from 1997 to 2012) of the population-based Swiss Health Interview Survey. Multivariable Poisson regressions with robust variance were used to estimate weighted prevalence ratio (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status and use of healthcare.

RESULTS

This study included 60,764 participants with a mean age of 49.1 years (standard deviation (SD) 17.2) and 53.6% of women. Between 1997 and 2012, the weighted prevalence of ever life-time skin examination and skin examination in the current year increased by 38.2% and 35.3% respectively (p-value <0.001). Participants with a lower education level, lower income and living in non-metropolitan areas were less often screened than their counterparts. Educational differences in ever life-time skin examination increased over time (p-value for trend = 0.036).

CONCLUSION

While skin cancer screening prevalence in Switzerland increased from 1997 to 2012, most social inequalities persisted over time and educational inequalities increased. Dermatologists should be alerted that populations with lower education should be given special attention.

Effects of the Training About Prostate Cancer and Screening Methods on Knowledge Level

This quasi-experimental study aims to identify the effects of the training about prostate cancer and screening methods given to men aged 40 and over on their knowledge level. It was found that there were no differences between the experimental and control groups in terms of the perceived susceptibility, perceived seriousness, health motivation, perceived barriers, and perceived benefits subscale mean scores, but the posttest data revealed that the perceived susceptibility, health motivation, and perceived benefits subscale mean scores of the experimental group were higher and their perceived barriers mean score was lower; the differences between the mean scores were statistically significant (p < .05, p < .01, p < .001). An analysis of the Health Belief Model after the training about prostate cancer and screening methods showed that the training was effective. Actually, the authors recommended that especially male nurses can play an effective role in training about prostate cancer and screening methods for men in Turkey.

Longer and healthier lives for all? Successes and failures of a universal consumer-driven healthcare system, Switzerland, 1990-2014

Objectives

The ability to translate increases in life expectancy into additional years in good health is a crucial challenge for public health policies. We question the success of these policies in Switzerland, a forerunner of longevity, through the evolution of healthy life expectancy (HLE) across socioeconomic groups.

Methods

Education-specific HLE conditioning on surviving to age 30 was computed for 5-year periods from the Swiss National Cohort, a mortality follow-up of the entire resident population, and the Swiss Health Interview Survey, reporting self-rated health. We compare time trends and decompose them into health, mortality and education components.

Results

Between 1990 and 2015, comparable gains in LE (males: 5.02 years; females: 3.09 years) and HLE (males: 4.52 years; females: 3.09 years) were observed. People with compulsory education, however, experienced morbidity expansion, while those with middle and high education experienced morbidity compression.

Conclusions

Divergence of morbid years by educational levels may reflect unequal access to preventive care due to high out-of-pockets contributions in the healthcare system. This growing gap and the exhaustion of the educational dividend jeopardize future increases in HLE.

Electronic supplementary material

The online version of this article (10.1007/s00038-019-01290-5) contains supplementary material, which is available to authorized users.

The impact of intimate partner violence on forgone healthcare: a population-based, multicentre European study

BACKGROUND

To examine the relationship between forgone healthcare and involvement in intimate partner violence (IPV) as victims, perpetrators or both.

METHODS

This cross-sectional multicentre study assessed community non-institutionalized residents (n = 3496, aged 18-64) randomly selected from six European cities: Athens, Budapest, London, Östersund, Porto, Stuttgart. A common questionnaire was used, including self-reports of IPV and forgone healthcare ('Have you been in need of a certain care service in the past year, but did not seek any help?'). Odds ratios (ORs), 95% confidence intervals (CIs) were computed fitting logistic regression models adjusted for city, chronic disease, self-assessed health status and financial strain.

RESULTS

Participants experiencing past year IPV (vs. no violence) reported more often to forgone healthcare (n = 3279, 18.6% vs. 15.3%, P = 0.016). IPV experienced as both a victim and perpetrator was associated with forgone healthcare (adjusted OR, 95%CI: 1.32, 1.02-1.70).

CONCLUSION

IPV was associated with forgone healthcare, particularly for those experiencing violence as both victims and perpetrators. Results suggest that preventing IPV among adults may improve timely healthcare uptake.

Commercial Health Care Financing: The Cause of U.S., Dutch, and Swiss Health Systems Inefficiency?

This article evaluates the performance of 3 industrialized nations that have pursued market-based financing models, focusing on equity in access to care, care quality, health status, and efficiency. It then assesses the consistency of the findings with those of different research teams. Using secondary data obtained from a semi-structured review of articles from 2000 to 2017, we discuss the hypothesis that commercial health care insurance is detrimental to accessing professional health care and to population health status. The results show that in 2010 the unmet care needs of both poor and rich Americans exceeded those of the poor in several industrial countries. The number of Dutch adults experiencing financial obstacles to health care quadrupled between 2007 and 2013, and 22% of Swiss adults reported skipping needed care in a 2016 survey. The most negative impacts of “managed care” on care quality are its tight constraints on physicians’ professional autonomy; a large reliance on the physicians’ material motivation; health service fragmentation; and the tendency to apply evidence-based medicine too rigidly. Countries with a commercial insurance monopoly generally remained above the maternal, infant, and neonatal mortality rates versus the health-spending regression line. We conclude that the most inefficient system is where the insurance market has achieved its maximal development and that care industrialization contributes to the comparatively poor performance of the U.S., Dutch, and Swiss health systems.

Organised population-based programmes and change in socioeconomic inequalities in mammography screening: A 1992-2012 nationwide quasi-experimental study

Organised mammography screening programmes may reduce socioeconomic inequalities in breast cancer screening, but evidence is contradictory. Switzerland has no national organised mammography screening programme, but regional programmes were progressively introduced since 1999, giving the opportunity to conduct a nationwide quasi-experimental study. We examined the evolution of socioeconomic inequalities in mammography screening in Switzerland and if exposure to regional organised programmes reduced socioeconomic inequalities. Data of 10,927 women aged 50 to 70 years old were collected from the Swiss Health Interview Survey, a nationally representative cross-sectional survey repeated 5 times (1992-2012). Socioeconomic characteristics were assessed using education, income, employment status, and occupational class. Adjusted prevalence ratios of up-to-date mammography screening were estimated with Poisson regressions and weighted for sampling strategy and non-participation bias. In the absence of organised screening programmes (1992-1997), prevalence of mammography screening increased by 23% and was associated with tertiary education and working part time. During the period of progressive introduction of regionally organised programmes (2002-2012), prevalence of mammography screening increased by 19% every 5 years and was associated with exposure to regional programmes and with independent/artisan occupations. Tertiary education and working part time were no longer associated. Exposure to organised programmes did not modify socioeconomic inequalities except for employment status: not employed women benefitted more from organised programmes compared to women working full time. In conclusion, socioeconomic inequalities in mammography screening decreased over time but organised programmes did not greatly modify them, except women not employed whose prevalence passed employed women.

Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage

Objectives

In countries with universal health coverage (UHC), national public health insurances cover 70% of health expenditures on average, but health care user fees and out-of-pocket expenditures have been neglected in empirical patient-centered health inequality research. This study is the first to investigate how health care-related factors are associated with health status among middle-aged and elderly people—vulnerable groups for the burden of illness—in countries with UHC.

Design

Longitudinal observational cohort study.

Setting

Population-based cohort Survey of Health, Ageing and Retirement in Europe (SHARE) in twelve countries with UHC.

Participants

Non-institutionalized people aged 50 and older (n = 29,260). Two subsamples were also used: participants without global activity limitation at baseline (n = 16,879) and participants without depression at baseline (n = 21,178).

Main outcome measures

Risk of death, risk of global activity limitations, and risk of depression. We used mixed-effects Cox proportional hazards regressions to estimate hazard ratios (HR) for all-cause mortality, physical limitations, and depression.

Results

Having a voluntary private insurance to cover health expenses not included in the public health care system (44.1% of the total sample) was a protective factor for all outcomes (HR≤0.91), controlling for a large range of socio-economic variables. On the contrary, having out-of-pocket expenditures (62.4%) was a risk factor (HR≥1.12).

Conclusions

UHC systems are not free from health inequalities: there is a potential effect of lack of voluntary private insurance and out-of-pocket expenditures on mortality and health. Health care-related factors should be at focus in future researches designed to understand and address health inequalities. Reducing out-of-pocket expenditures and developing voluntary private insurance may protect against premature illness and death.

Improvement of the reduction in catastrophic health expenditure in China's public health insurance

This study aimed to locate the contributing factors of Catastrophic Health Expenditure (CHE), evaluate their impacts, and try to propose strategies for reducing the possibilities of CHE in the context of China’s current public health insurance system. The financial data of all hospitalization cases from a sample hospital in 2013 were gathered and used to determine the pattern of household medical costs. A simulation model was constructed based on China’s current public health insurance system to evaluate the financial burden for medical service on Chinese patients, as well as to calculate the possibilities of CHE. Then, by adjusting several parameters, suggestions were made for China’s health insurance system in order to reduce CHE. It’s found with China’s current public health insurance system, the financial aid that a patient may receive depends on whether he is from an urban or rural area and whether he is employed. Due to the different insurance policies and the wide income gap between urban and rural areas, rural residents are much more financially vulnerable during health crisis. The possibility of CHE can be more than 50% for low-income rural families. The CHE ratio can be dramatically lowered by applying different policies for different household income groups. It’s concluded the financial burden for medical services of Chinese patients is quite large currently, especially for those from rural areas. By referencing different healthcare policies in the world, applying different health insurance policies for different income groups can dramatically reduce the possibility of CHE in China.

Adherence of patients with type 2 diabetes mellitus to medications: the role of risk preferences

OBJECTIVE

To examine whether risk tolerance is associated with adherence to oral hypoglycemic agents (OHAs).

METHODS

We performed a cross-sectional study among adult patients with type 2 diabetes mellitus (n = 308) presenting for routine out-patient visits, using validated questionnaires to estimate: risk preferences (risk-seeking, risk averse, risk neutral), motivation, self-efficacy, impulsivity, perception of the disease and of the interpersonal process of care, demographic and socioeconomic characteristics; computerized patient medical records to estimate disease severity and a computerized database for retrieval of medication adherence, 1 year before the interview. Adherence was estimated using prescription-based measures of proportion of days covered (PDC). Concurrent adherence was calculated as: PDC with ≥1 OHAs; average PDC; PDC of ≥80% for all OHAs.

RESULTS

Multivariable ordered logit model revealed that compared to others, risk-seeking patients had lower PDC with ≥1 OHAs (β = -0.50, p ≤ .1). Specifically, risk-seeking patients were 11.2 percentage points less likely to have ≥80% of the follow-up period covered with ≥1 OHAs available (p ≤ .1). In addition, risk-seeking patients had lower average PDC (β = -0.85, p ≤ .05). Specifically, these patients were 19.5 percentage points less likely to have an average PDC of ≥80% (p ≤ .05). Multivariable logistic model revealed that risk-seeking was associated with lower probability of having PDC ≥80% for all OHAs in the follow-up period (OR; 90% CI: 0.59; 0.35-0.97).

CONCLUSIONS

Risk-seeking patients are less adherent to OHA medications. Identifying these patients may enable practitioners to proactively tailor strategies to improve their adherence and health outcomes.

Addictive behaviors and healthcare renunciation for economic reasons in a French population-based sample

BACKGROUND

Healthcare renunciation for economic reasons is a major health concern, but it has been scarcely investigated among drug users, even if drug users constitute a vulnerable population in need of medical care. This study investigated associations of healthcare renunciation for economic reasons and addictive behaviors (alcohol, tobacco, cannabis, illicit drug use, and gambling) in a population-based sample of adults living in France, a country with universal health coverage.

METHODS

Data were collected using the 2014 Health Barometer, a French cross-sectional survey conducted among a random representative sample of the general population aged 18-64 (n=12,852). Measures included healthcare renunciation, substance use (alcohol, tobacco, cannabis, and other illicit drugs) and gambling. Experimental/recreational and heavy/chronic use were assessed. Logistic regressions were used to test the relationship between healthcare renunciation and addictive behaviors, controlling for relevant covariates.

RESULTS

A total of 25% of the participants had renounced care at least once in the previous twelve months. Most variables of drug use were significantly associated with increased healthcare renunciation. This was the case for heavy/hazardous use and experimental/recreational use. Regular gambling was not associated with healthcare renunciation, but disordered gambling was.

CONCLUSION

This study showed that addictive behaviors, including substance use and gambling, were part of the burden of vulnerability of people who forgo care. Therefore, drug use and gambling patterns should be a focus in the development of policies to reduce health inequalities, not only for heavy and chronic drug users.

Determinants associated with deprivation in multimorbid patients in primary care-A cross-sectional study in Switzerland

BACKGROUND

Deprivation usually encompasses material, social, and health components. It has been shown to be associated with greater risks of developing chronic health conditions and of worse outcome in multimorbidity. The DipCare questionnaire, an instrument developed and validated in Switzerland for use in primary care, identifies patients subject to potentially higher levels of deprivation.

OBJECTIVES

To identifying determinants of the material, social, and health profiles associated with deprivation in a sample of multimorbid, primary care patients, and thus set priorities in screening for deprivation in this population.

DESIGN

Secondary analysis from a nationwide cross-sectional study in Switzerland.

PARTICIPANTS

A random sample of 886 adult patients suffering from at least three chronic health conditions.

MAIN MEASURES

The outcomes of interest were the patients' levels of deprivation as measured using the DipCare questionnaire. Classification And Regression Tree analysis identified the independent variables that separated the examined population into groups with increasing deprivation scores. Finally, a sensitivity analysis (multivariate regression) confirmed the robustness of our results.

KEY RESULTS

Being aged under 64 years old was associated with higher overall, material, and health deprivation; being aged over 77 years old was associated with higher social deprivation. Other variables associated with deprivation were the level of education, marital status, and the presence of depression or chronic pain.

CONCLUSION

Specific profiles, such as being younger, were associated with higher levels of overall, material, and health deprivation in multimorbid patients. In contrast, patients over 77 years old reported higher levels of social deprivation. Furthermore, chronic pain and depression added to the score for health deprivation. It is important that GPs consider the possibility of deprivation in these multimorbid patients and are able to identify it, both in order to encourage treatment adherence and limit any forgoing of care for financial reasons.

Healthcare renunciation among young adults in French higher education: A population-based study

Healthcare renunciation has been a recent focus of the public health debate, but large-scale investigations of healthcare renunciation are scarce. The goal of this study was to examine healthcare renunciation among young adults at French universities. It investigated prevalence of and reasons for healthcare renunciation and identified subgroups of vulnerable youths. Data were collected in the 2013 triennial study conducted by the French National Observatory of Student Life. That study had a sample of 35,810 18- to 25-year-old participants. Measures included healthcare renunciation, reasons for healthcare renunciation, demographics, cultural and socioeconomic background, health and social outcomes, healthcare system-related variables, and markers of adulthood. The results showed that the prevalence of healthcare renunciation was 27.2%. The most common reasons for healthcare renunciation were refusal renunciation (self-care, 12.7%; wait for improvement, 15.5%) and barrier renunciation (financial reasons, 12.1%; lack of time, 10.2%). Therefore, healthcare renunciation is linked not only to financial constraints but also to individuals' subjective needs and ways of facing illness. Overall, disadvantaged youths and youths transitioning to adulthood were likelier to renounce care, especially for financial reasons. To conclude, there are social inequalities in the use of healthcare by emerging adults in higher education in France. Emerging adulthood appears to be a risky period in which people are likely to renounce healthcare for multiple reasons. Support should be provided for vulnerable youths to prevent them from becoming increasingly vulnerable.

Cervical cancer screening in Switzerland: cross-sectional trends (1992-2012) in social inequalities

Background: Incidence and mortality of cervical cancer declined thanks to Pap smear screening. However cervical cancer screening (CCS) inequalities are documented, including in high income countries. This population-based study aims to assess the importance and 20-year trends of CCS inequalities in Switzerland, where healthcare costs and medical coverage are among the highest in the world. Methods: We analyzed data from five waves of the population-based Swiss Health Interview Survey (SHIS) covering the period 1992–2012. Multivariable Poisson regression were used to estimate weighted prevalence ratios (PR) of CCS and 95% Confidence Intervals (CI) adjusting for socio-economic, socio-demographic characteristics, family status, health status, and use of healthcare. Results: The study included 32’651 women aged between 20 and 70 years old. Between 1992 and 2012, rates of CCS over the past 3 years fluctuated between 71.7 and 79.6% (adjusted P < 0.001). Lower CCS was observed among women with low education, low income, those having limited emotional support, who were non-Swiss, single, older, living in non-metropolitan area or in the French-speaking region, overweight. Over the analyzed period, differences in CCS across age groups diminished while rates among women who visited a GP over the previous year, versus those who did not, increased. Conclusions : While important changes occurred in screening recommendations and in social circumstances of the targeted population, CCS rates remained fairly stable in Switzerland between 1992 and 2012. At the same time, inequalities in CCS persisted over that period.

[Factors associated with dental care use among a population of Moroccan adolescents]

INTRODUCTION

Untreated dental caries are a major public health concern because of the impact on quality of life and of the high cost of dental care. Our aim was to identify factors related to dental care use among a population of urban Moroccan adolescents.

MATERIAL AND METHODS

A cross-sectional study involving adolescents in an urban area was conducted. Adolescents were recruited in high schools selected by a cluster sampling method. The studied variables were recorded through a questionnaire and oral examinations. Collected data were socio-demographic parameters, medical insurance status and oral health status using DMFT (Decayed, Missing, Filled Teeth) and SiC (Significant Caries Index) indexes. Logistic regression analysis was applied to evaluate factors associated to dental care use.

RESULTS

Four hundred and fifty adolescents were included in 2012 and 2013. Three hundred and eighty seven (86%) had one untreated dental caries at least. One hundred and seventy-one (38%) had at least one filled teeth. Logistic regression analysis showed that health insurance status, parental income, gender and DMFT index were statistically significant variables associated to dental care use.

DISCUSSION

Renouncement to dental care is not only related to the lack of medical insurance. Other factors such as gender and income level seems to be as important.

Failure to pay for social health insurance premiums: Acts of protest or desperation?

Background

In Switzerland, basic health insurance is mandatory for all inhabitants, but a rising number of insured have arrears in premium payments, potentially leading to coverage suspension. We aimed at characterizing insured with debt enforcement proceedings with respect to socio-demographic and health utilization aspects.

Methods

Cross-sectional analysis of 508.000 insured with basic health insurance contracts in 2013, of whom 14,000 (2.8%) with debt enforcement proceedings, from 11 Swiss cantons. Groups were characterized using logistic regression and latent class analysis.

Results

Insured with debt enforcement proceedings were more likely to be young, male and without dependents (partner, kids). Having no supplementary insurance and receiving partial premium subsidies was associated with an increased debt enforcement proceedings risk.

Within the debt enforcement proceedings group, three subgroups were identified: 60% were young and seemingly healthy, with a below-average fraction of premium subsidy recipients (18%) and low out-of-pocket payments in prior year (median Swiss Francs 0).

Two groups consisted of relatively ill elderly persons (22%, 99% of whom with chronic illnesses) or families (18%), many of whom (29% and 51%) were recipients of premium subsidies. Median out-of-pocket payments in the prior year were high (Swiss Francs 625 and 688, respectively).

Conclusions

Sixty percent of premium arrears derive from young insured without apparent financial problems; 40% are owed by elderly and families, which are potentially hurt by coverage loss.

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Failure to pay for Swiss mandatory health insurance can lead to coverage suspension.

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Arrears for mandatory insurance have risen over last years, but reasons are unclear.

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60% of arrears pertain to young, single persons with low health care utilization.

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40% of arrears concern chronically ill elderly or families.

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Coverage suspension to enforce payment discipline may hurt vulnerable populations.

Prostate cancer screening in Switzerland: 20-year trends and socioeconomic disparities

BACKGROUND

Despite important controversy in its efficacy, prostate cancer (PCa) screening has become widespread. Important socioeconomic screening disparities have been reported. However, trends in PCa screening and social disparities have not been investigated in Switzerland, a high risk country for PCa. We used data from five waves (from 1992-2012) of the population-based Swiss Health Interview Survey to evaluate trends in PCa screening and its association with socioeconomic indicators.

METHODS

We used multivariable Poisson regression to estimate prevalence ratios (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status, and use of healthcare.

RESULTS

The study included 12,034 men aged ≥50 years (mean age: 63.9). Between 1992 and 2012, ever use of PCa screening increased from 55.3% to 70.0% and its use within the last two years from 32.6% to 42.4% (p-value <0.05). Income, education, and occupational class were independently associated with PCa screening. PCa screening within the last two years was greater in men with the highest (>$6,000/month) vs. lowest income (≤$2,000) (46.5% vs. 38.7% in 2012, PR for overall period =1.29, 95%CI: 1.13-1.48). These socioeconomic disparities did not significantly change over time.

CONCLUSIONS

This study shows that about half of Swiss men had performed at least one PCa screening. Men belonging to high socioeconomic status are clearly more frequently screened than those less favored. Given the uncertainty of the usefulness of PCa screening, men, including those with high socioeconomic status, should be clearly informed about benefits and harms of PCa screening, in particular, the adverse effect of over-diagnosis and of associated over-treatment.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study

BACKGROUND

Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability.

METHODS

A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used.

RESULTS

We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2).

CONCLUSIONS

Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.