Should a patient's socioeconomic status count in decisions about treatment in medical care? A longitudinal study of Norwegian doctors

AIMS

The major causes of social inequalities in health are found outside of healthcare. However, healthcare can also play a role in maintaining, reducing, or reinforcing inequality. We present and discuss results from a panel study of doctors' views on whether and how socioeconomic factors should play a role in clinical decision making.

METHODS

The panel comprised a representative sample of Norwegian doctors, established in 1994. For the current study, the doctors received postal questionnaires in 2008, 2012 and 2016. Data were analysed using descriptive statistics, correlation analysis, factor analysis and mixed models for repeated measurements.

RESULTS

The sample sizes were 1072 (65%), 1279 (71%) and 1605 (73%), respectively. The doctors were increasingly positive towards considering socioeconomic factors, and reported giving more time and advice and asking for less pay to compensate for unfavorable socioeconomic factors. General practitioners were more likely to consider socioeconomic factors and changed their practice accordingly compared to other clinicians. The percentage of doctors who agreed that different amounts of resources should be used to obtain similar health effects was high and increased over time.

CONCLUSIONS

Increasingly more doctors are willing to consider patients' socioeconomic factors in clinical care. This could be contrary to professional ethics, in which only medical need should count. However, it depends on how 'need' is interpreted. As treatment outcomes partly depend on non-medical factors, socioeconomic factors should be considered because they influence patients' ability to benefit from medical care. Equality requires mitigating factors with negative impacts on health outcomes.

Stability and change in disease prestige: A comparative analysis of three surveys spanning a quarter of a century

In this paper, we present a comparative analysis of three survey studies of disease prestige in medical culture. The studies were conducted in 1990, 2002 and 2014 using the same research design. In each of the three rounds, a sample of Norwegian physicians was asked to rate a set of 38 diseases on a scale from 1 to 9 according to the prestige they believed health personnel in general would award them. The results show a remarkable stability in the prestige rank order over 25 years. The top three diseases in all three surveys were leukaemia, brain tumour and myocardial infarction. The four lowest ranked were fibromyalgia, depressive neurosis, anxiety neurosis and hepatocirrhosis. The most notable change concerns apoplexy (brain stroke), which moved from a rank of 33 to 29 and then to 23 over the three rounds. We argue that the stable pattern, as well as this change, substantiate the interpretation of previous research, i.e. that the prestige of a disease is affected by the localization of the affected organ or body part, the effect and style of its typical treatment, and the social attributes of the typical patient. Analysing physicians' shared evaluations of different diseases, the paper contributes to the cultural understanding of disease conceptions in medicine. Understanding these conceptions is important because disease prestige may influence decision-making in the healthcare sector.

How common is change of primary diagnosis during an episode of sickness benefit? A register study of medical sickness certificates issued 2010-2012 in Sweden

AIM

The aims of this study were to investigate how common it is to change primary diagnosis between different diagnostic chapters during a sick-leave spell, and to explore patterns of diagnostic changes.

METHODS

The unit for analysis was episode of sickness benefit, that is, sick leave >14 days, which commenced between 2010 and 2012 in Sweden. For each case, the primary diagnosis was retrieved from the first and last/latest medical sickness certificate, respectively. The number of days of sickness benefit was linked to the cases. Any change of primary diagnosis was analysed by diagnostic chapter according to the ICD-10, and this was done separately for women and men.

RESULTS

In total, 803,041 cases of sickness benefit (63% women) were included in the study. During a sick-leave spell, 7.1% of female cases and 6.6% of male cases changed their primary diagnosis to a diagnosis from another diagnostic chapter. The change of primary diagnosis increased with the number of days with sickness benefit. For female cases, this increase was from 2.0% for cases that lasted 15-30 days to 20.2% for cases that lasted >365 days. For male cases, the corresponding increase was from 1.8% to 21.2%. A change of primary diagnosis was least common among those initially sick-listed for mental disorders and musculoskeletal disorders. The patterns of diagnostic changes were rather similar for women and men.

CONCLUSIONS

A change of diagnosis during a sick-leave spell needs to be taken into consideration by the sickness insurance system and in the actions taken by its administration. Registry-based studies of sickness insurance need to consider diagnostic changes in both the study design and the interpretation of results.