Trends In Inequalities In Mortality Amenable To Health Care In 17 European Countries

The contribution of avoidable mortality to life expectancy differences and lifespan disparities in the European Union: a population-based study

Background

Twenty years after the 2004 European Union (EU) enlargement, life expectancy differences between established (EMS) and new member states (NMS) remain large. Contributing to this gap are deaths that can be avoided through preventive services or adequate medical treatment. We estimate the impact of reducing avoidable mortality on life expectancy and lifespan disparities in the enlarged EU.

Methods

Using World Health Organization mortality database data, we analysed the potential of reducing avoidable mortality, as defined by Eurostat and the Organisation for Economic Cooperation and Development, to close the mortality gap between NMS and EMS. We decomposed the changes in life expectancy and lifespan disparity by age and cause using linear integral decomposition.

Findings

Averting all avoidable deaths across the EU from 2005 to 2019 would decrease the average life expectancy gap from 5.8 to 2.4 years in men and 3.3-2 years in women and eliminate the lifespan disparity gap. Had NMS achieved the average EMS avoidable mortality rates during the same period, the average life expectancy gap would have been reduced to 1.8 years in men and 1.6 years in women, and the lifespan disparities gap would have been reversed. Avoidable circulatory and injury-related deaths in middle and older age drove the observed mortality changes.

Interpretation

Our results suggest that the gap in life expectancy and lifespan disparity across the EU could be reduced by strengthening health systems and investing in averting circulatory and injury-related deaths in middle and older age in NMS.

Funding

None.

Lifetime healthcare expenditures across socioeconomic groups

BACKGROUND

A socioeconomic gradient affects healthcare expenditures and longevity in opposite directions as less affluent individuals have higher current healthcare expenditures but simultaneously enjoy shorter lives. Yet, it is unclear whether this cross-sectional healthcare expenditure gradient persists from a lifetime perspective. This paper analyzes lifetime healthcare expenditures across socioeconomic groups using detailed individual-level healthcare expenditure data for the entire Danish population.

METHOD

Using full population healthcare expenditures from Danish registries, we estimate lifetime healthcare expenditures as age-specific mean healthcare expenditures times the probability of being alive at each age. Our data enables the estimation of lifetime healthcare expenditures by sex, socioeconomic status, and by various types of healthcare expenditure.

RESULTS

Once we account for mortality differences and all types of healthcare expenditures, all socioeconomic groups spend an almost equal amount on healthcare throughout a lifetime. Lower socioeconomic groups incur the lowest lifetime hospital expenditures, whereas higher socioeconomic groups experience the highest lifetime expenditures on long-term care services. Our findings remain robust across various socioeconomic measures and alternative estimation methodologies.

CONCLUSION

Improving the health status of lower socioeconomic groups to align with that of higher socioeconomic groups is costly but may ultimately reduce current healthcare expenditures. Enhanced health outcomes likely increase lifespan, leading to extended periods of healthcare consumption. However, since all socioeconomic groups tend to have similar lifetime healthcare expenditures, this prolonged consumption has limited impact on overall lifetime healthcare costs. Additionally, a significant benefit is the deferment of healthcare expenditures into the future. Overall, our results diminish concerns about socially inequitable utilization of healthcare resources while socioeconomic differences in health and longevity persist, even in a universal healthcare system.

Socioeconomic inequalities in avoidable mortality in Italy: results from a nationwide longitudinal cohort

BACKGROUND

Disparities in avoidable mortality have never been evaluated in Italy at the national level. The present study aimed to assess the association between socioeconomic status and avoidable mortality.

METHODS

The nationwide closed cohort of the 2011 Census of Population and Housing was followed up for 2012-2019 mortality. Outcomes of preventable and of treatable mortality were separately evaluated among people aged 30-74. Education level (elementary school or less, middle school, high school diploma, university degree or more) and residence macro area (North-West, North-East, Center, South-Islands) were the exposures, for which adjusted mortality rate ratios (MRRs) were calculated through multivariate quasi-Poisson regression models, adjusted for age at death. Relative index of inequalities was estimated for preventable, treatable, and non-avoidable mortality and for some specific causes.

RESULTS

The cohort consisted of 35,708,459 residents (48.8% men, 17.5% aged 65-74), 34% with a high school diploma, 33.5% living in the South-Islands; 1,127,760 deaths were observed, of which 65.2% for avoidable causes (40.4% preventable and 24.9% treatable). Inverse trends between education level and mortality were observed for all causes; comparing the least with the most educated groups, a strong association was observed for preventable (males MRR = 2.39; females MRR = 1.65) and for treatable causes of death (males MRR = 1.93; females MRR = 1.45). The greatest inequalities were observed for HIV/AIDS and alcohol-related diseases (both sexes), drug-related diseases and tuberculosis (males), and diabetes mellitus, cardiovascular diseases, and renal failure (females). Excess risk of preventable and of treatable mortality were observed for the South-Islands.

CONCLUSIONS

Socioeconomic inequalities in mortality persist in Italy, with an extremely varied response to policies at the regional level, representing a possible missed gain in health and suggesting a reassessment of priorities and definition of health targets.

Disruption of hospital care during the first year of the COVID-19 pandemic impacted socioeconomic groups differently: population based study using routine registration data

BACKGROUND

During the COVID-19 pandemic, provision of non-COVID healthcare was recurrently severely disrupted. The objective was to determine whether disruption of non-COVID hospital use, either due to cancelled, postponed, or forgone care, during the first pandemic year of COVID-19 impacted socioeconomic groups differently compared with pre-pandemic use.

METHODS

National population registry data, individually linked with data of non-COVID hospital use in the Netherlands (2017-2020). in non-institutionalised population of 25-79 years, in standardised household income deciles (1 = low, 10 = high) as proxy for socioeconomic status. Generic outcome measures included patients who received hospital care (dichotomous): outpatient contact, day treatment, inpatient clinic, and surgery. Specific procedures were included as examples of frequently performed elective and acute procedures, e.g.: elective knee/hip replacement and cataract surgery, and acute percutaneous coronary interventions (PCI). Relative risks (RR) for hospital use were reported as outcomes from generalised linear regression models (binomial) with log-link. An interaction term was included to assess whether income differences in hospital use during the pandemic deviated from pre-pandemic use.

RESULTS

Hospital use rates declined in 2020 across all income groups. With baseline (2019) higher hospital use rates among lower than higher income groups, relatively stronger declines were found for lower income groups. The lowest income groups experienced a 10% larger decline in surgery received than the highest income group (RR 0.90, 95% CI 0.87 - 0.93). Patterns were similar for inpatient clinic, elective knee/hip replacement and cataract surgery. We found small or no significant income differences for outpatient clinic, day treatment, and acute PCI.

CONCLUSIONS

Disruption of non-COVID hospital use in 2020 was substantial across all income groups during the acute phases of the pandemic, but relatively stronger for lower income groups than could be expected compared with pre-pandemic hospital use. Although the pandemic's impact on the health system was unprecedented, healthcare service shortages are here to stay. It is therefore pivotal to realise that lower income groups may be at risk for underuse in times of scarcity.

Evaluating the effects of the 2017 National Health Insurance coverage expansion on amenable mortality and its disparities between areas in South Korea using Bayesian structural time-series models

To improve the low coverage rate of the National Health Insurance (NHI), South Korea implemented the NHI coverage expansion plan in 2017 to cover medically essential non-covered services and reduce copayment rates. This study aimed to estimate the effects of the 2017 NHI coverage expansion on amenable mortality and its disparities between areas in South Korea under a controlled interrupted time-series design using Bayesian structural time-series models. Age-standardized amenable mortality rates and rate differences (RDs) and rate ratios (RRs) between areas for amenable mortality were calculated monthly between July 2012 and December 2021 and used as the response series. The non-equivalent control series were monthly non-avoidable mortality rates and their regional disparities. After the coverage expansion, amenable mortality rates decreased for both males (-8.8%, 95% credible interval [CrI] -13.4% to -3.9%) and females (-8.3%, 95% CrI -13.4% to -2.4%), with the largest decline in the non-Seoul-Capital metropolitan area (-11.6%, 95% CrI -16.5% to -6.3%) rather than the Seoul Capital Area (-7.5%, 95% CrI -11.9% to -2.5%) and a non-significant reduction in the non-Seoul-Capital non-metropolitan area in females. RDs and RRs between areas for amenable mortality decreased non-significantly (-16.2%, 95% CrI -31.3% to 2.6% for RD and -1.2%, 95% CrI -3.7% to 1.5% for RR), except for a significant decrease in RD in males (-21.8%, 95% CrI -38.0% to -1.5%), and decreased less in females than in males. The coverage expansion was generally effective in reducing amenable mortality rates by area, but had limited effects in closing amenable mortality disparities between areas, favoring males and the non-Seoul-Capital metropolitan area. These results implied that additional measures are necessary to improve access to quality health care for females and underserved areas to enhance the effectiveness of the coverage expansion.

Essential cancer medicines and cancer outcomes: Cross-sectional study of 124 countries

BACKGROUND

Cancer is the second leading cause of death worldwide. Alongside other interventions, access to certain medicines may decrease cancer-associated mortality. Listing medicines on national essential medicines lists may improve health outcomes. We examine the association between cancer mortality amenable to care and the listing of cancer medicines on national essential medicines lists (NEMLs) of 124 countries.

METHODS

In this cross-sectional study, we determined the number of medicines used to treat eight cancers on NEMLs and used multiple linear regression to analyze the association between cancer health outcome scores and the number of medicines on NEMLs while controlling for GDP. A sensitivity analysis was also conducted using selected medicines.

FINDINGS

The number of cancer medicines on NEMLs was not associated with cancer health outcome scores when GDP was controlled for non-melanoma skin (p = 0.224), uterine (p = 0.221), breast (p = 0.145), Hodgkin's lymphoma (p = 0.697), colon (p = 0.299), leukemia (p = 0.103), cervical (p = 0.834), and testicular cancers (p = 0.178).

INTERPRETATION

There was a weak association between listing medicines for eight cancers in NEMLs and amenable mortality. Further studies are required to explore association between cancer health outcomes and other factors such as actual availability of medicines listed, access to surgeries, accurate diagnosis, radiotherapy, and early detection.

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.

Is the uptake, engagement, and effectiveness of exclusively mobile interventions for the promotion of weight-related behaviors equal for all? A systematic review

Mobile health interventions are promising behavior change tools. However, there is a concern that they may benefit some populations less than others and thus widen inequalities in health. This systematic review investigated differences in uptake of, engagement with, and effectiveness of mobile interventions for weight-related behaviors (i.e., diet, physical activity, and sedentary behavior) based on a range of inequality indicators including age, gender, race/ethnicity, and socioeconomic status. The protocol was registered on PROSPERO (CRD42020192473). Six databases (CINAHL, EMBASE, ProQuest, PsycINFO, Pubmed, and Web of Science) were searched from inception to July 2021. Publications were eligible for inclusion if they reported the results of an exclusively mobile intervention and examined outcomes by at least one inequality indicator. Sixteen publications reporting on 13 studies were included with most reporting on multiple behaviors and inequality indicators. Uptake was investigated in one study with no differences reported by the inequality indicators studied. Studies investigating engagement (n = 7) reported differences by age (n = 1), gender (n = 3), ethnicity (n = 2), and education (n = 2), while those investigating effectiveness (n = 9) reported differences by age (n = 3), gender (n = 5), education (n = 2), occupation (n = 1), and geographical location (n = 1). Given the limited number of studies and their inconsistent findings, evidence of the presence of a digital divide in mobile interventions targeting weight-related behaviors is inconclusive. Therefore, we recommend that inequality indicators are specifically addressed, analyzed, and reported when evaluating mobile interventions.

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019.

METHODS

We distinguished the overall HAQ Index (ages 0-74 years) from scores for select age groups: the young (ages 0-14 years), working (ages 15-64 years), and post-working (ages 65-74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development.

FINDINGS

Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9-21·3), as well as among the young (22·5, 19·9-24·7), working (17·2, 15·2-19·1), and post-working (15·1, 13·2-17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6-33·0) on average in low-SDI countries to 83·4 (82·4-84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4-89·0), working (33·8-82·8), and post-working (30·4-79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries.

INTERPRETATION

Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.

FUNDING

Bill & Melinda Gates Foundation.

Self-Medication Behaviors of Chinese Residents and Consideration Related to Drug Prices and Medical Insurance Reimbursement When Self-Medicating: A Cross-Sectional Study

BACKGROUND

Self-medication has become a common phenomenon. Economic factors are important factors that affect the self-medication of residents. This study aimed to investigate the current status of self-medication behaviors in China and explored the related factors affecting considerations associated with medical insurance reimbursement or drug price in self-medication.

METHODS

A national cross-sectional investigation was conducted among Chinese people over 18 years old under a multi-stage sampling method through a questionnaire, which includes demographic sociological characteristics, self-medication behaviors and scales. The Chi-square test was used to analyze whether the respondents consider medical insurance reimbursement or drug price as an important factor when purchasing over-the-counter (OTC) drugs. Logistic regression was used to examine the associated factors of considering medical insurance reimbursement or drug price.

RESULTS

In total, 9256 respondents were included in this study; 37.52% of the respondents regarded drug prices as an important consideration, and 28.53% of the respondents attached great importance to medical insurance reimbursement. Elderly respondents who lived in the central region, had medical insurance, and had lower levels of health literacy were more likely to consider the medical insurance reimbursement, while respondents with high monthly family income as well as students were less likely to consider the same issue (p < 0.05). Respondents settled in the central and western regions, students, those without fixed occupations, those who suffered from chronic diseases, or those with lower health literacy were more likely to consider drug prices, while the respondents with bachelor degrees, urban population and high per capita monthly income were less likely to consider the drug prices (p < 0.05).

CONCLUSION

Self-medication behaviors with OTC drugs were prevalent in China, and consideration factors of medical insurance reimbursement or drug prices were related to socio-demographic characteristics and health literacy. There is a need to take measures to reduce the economic burden of self-medication, improve the health literacy of residents and strengthen public health education.

Macro-level factors explaining inequalities in expected years lived free of and with chronic conditions across Spanish regions and over time (2006-2019)

Life expectancy has long been associated with macro-level factors, including health expenditures, but little research has focused on the relationship with morbidity measures. This paper examines the relationship between the expected years lived free of and with chronic conditions (YLFCC and YLCC) at age 50 and macroeconomic and social factors including, for the first time, several indicators of public health expenditure. We calculate YLFCC and YLCC for Spanish regions using the Sullivan method over a long period of time (2006-2019). Spain is a good case study due to two reasons. First, its national health system is decentralized among regional administrations since 2002. Second, the financial crisis of 2008 led to public health cuts in 2010-2014 that each region handled differently. We use fixed-effects models to assess the relationship between changes in macro-level regional indicators (socioeconomic factors, healthcare resources, health behavior and public health expenditures) with YLFCC and YLCC across regions and over time. Results show that socioeconomic levels, public health expenditure, healthcare resources and health behaviors are associated with years lived free of and with chronic conditions when analyzing them independently. However, in the global model including all these dimensions only public health expenditure is associated with both YLFCC and YLCC for men and women, showing that a higher level of expenditures is correlated with more YLFCC and less YLCC. Therefore, regional authorities need to pay special attention to the level of investments on health services, as they are clearly associated with a better quality of living of the middle age and older population.

Trends and disparities in avoidable, treatable, and preventable mortalities in South Korea, 2001-2020: comparison of capital and non-capital areas

OBJECTIVES

This study aimed to describe the regional avoidable mortality trends in Korea and examine the trends in avoidable mortality disparities between the Seoul Capital Area and non-Seoul-Capital areas, thereby exploring the underlying reasons for the trend changes.

METHODS

Age-standardized mortality rates from avoidable causes between 2001-2020 were calculated by region. Regional disparities in avoidable mortality were quantified on both absolute and relative scales. Trends and disparities in avoidable mortality were analyzed using joinpoint regression models.

RESULTS

Avoidable, treatable, and preventable mortalities in Korea decreased at different rates over time by region. The largest decreases were in the non-Seoul-Capital non-metropolitan area for avoidable and preventable mortality rates and the non-Seoul- Capital metropolitan area for treatable mortality rates, despite the largest decline being in the Seoul Capital Area prior to around 2009. Absolute and relative regional disparities in avoidable and preventable mortalities generally decreased. Relative disparities in treatable mortality between areas widened. Regional disparities in all types of mortalities tended to improve after around 2009, especially among males. In females, disparities in avoidable, treatable, and preventable mortalities between areas improved less or even worsened.

CONCLUSIONS

Trends and disparities in avoidable mortality across areas in Korea seem to have varied under the influence of diverse social changes. Enhancing health services to underserved areas and strengthening gender-oriented policies are needed to reduce regional disparities in avoidable mortality.

The Impact of Dependency Burden on Urban Household Health Expenditure and Its Regional Heterogeneity in China: Based on Quantile Regression Method

Background

The aging population has led to a growing health expenditure burden. According to the National Bureau of Statistics of China, the old-age dependency ratio rose from 10.7% in 2003 to 17.8% in 2019, and health expenditure increased from 658.410 billion yuan in 2003 to 5812.191 billion yuan in 2019 in China.

Methods

This paper utilizes the quantile regression method to discuss the influencing factors of health expenditure in urban China based on the China Household Finance Survey (CHFS), especially dependency burden. Moreover, its regional heterogeneity is also compared.

Results

The old-age dependency ratio, age, family size, self-rated health status, and income significantly impact the health expenditure of urban families in the quantile regression of the national sample. Dependency burden and other variables on urban household health expenditure have great regional heterogeneity. The relationship between urban health expenditure and residential areas in western China is more stable than that in eastern and central China.

Discussion

Government should improve the healthcare system suitable for the older adult population as soon as possible. The government of western China should pay more attention to the introduction of professional medical talents and the configuration of precision medical equipment to improve the health system in western China.

Socio-economic inequalities in rates of amenable mortality in Scotland: Analyses of the fundamental causes using the Scottish Longitudinal Study, 1991-2010

Socio-economic inequalities in amenable mortality rates are increasing across Europe, which is an affront to universal healthcare systems where the numbers of, and inequalities in, amenable deaths should be minimal and declining over time. However, the fundamental causes theory proposes that inequalities in health will be largest across preventable causes, where unequally distributed resources can be used to gain an advantage. Information on individual-level inequalities that may better reflect the fundamental causes remains limited. We used the Scottish Longitudinal Study, with follow-up to 2010 to examine trends in amenable mortality by a range of socioeconomic position measures. Large inequalities were found for all measures of socioeconomic position and were lowest for educational attainment, higher for social class and highest for social connection. To reduce inequalities, amenable mortality needs to be interpreted both as an indicator of healthcare quality and as a reflection of the unequal distribution of socio-economic resources.

The Devil Is in the Data: Can Regional Variation in Amenable Mortality Help to Understand Changes in Health System Performance in Poland?

The contribution of health systems to health is commonly assessed using levels of amenable mortality. Few such studies exist for Poland, with analyses of within-the-country patterns being particularly scarce. The aim of this paper is to analyse differences in amenable mortality levels and trends across Poland's regions using the most recent data and to gain a more nuanced understanding of these differences and possible reasons behind them. This can inform future health policy decisions, particularly when it comes to efforts to improve health system performance. We used national and regional mortality data to construct amenable mortality rates between 2002 and 2019. We found that the initially observed decline in amenable mortality stagnated between 2014 and 2019, something not seen elsewhere in Europe. The main driver behind this trend is the change in ischemic heart disease (IHD) mortality. However, we also found that there is a systematic underreporting of IHD as a cause of death in Poland in favour of heart failure, which makes analysis of health system performance using amenable mortality as an indicator less reliable. We also found substantial geographical differences in amenable mortality levels and trends across Poland, which ranged from -3.3% to +8.1% across the regions in 2014-2019. These are much bigger than variations in total mortality trends, ranging from -1.5% to -0.2% in the same period, which suggests that quality of care across regions varies substantially, although some of this effect is also a coding artefact. This means that interpretation of health system performance indicators is not straightforward and may prevent implementation of policies that are needed to improve population health.

Avoidable mortality for causes amenable to medical care and suicide in physicians in Spain

OBJECTIVE

To compare avoidable mortality for causes amenable to medical care and suicide in physicians versus other professionals with similar university studies and socioeconomic position in Spain.

METHODS

All people aged 25-64 years who were employed on 1 November 2001 (8,697,387 men and 5,282,611 women) were included. Their vital status was followed for 10 years and the cause of death of deceased was recorded. Using a Poisson regression to estimate the mortality rate ratio (MRR), we compared mortality due to causes of death amenable to medical care, all other causes, and suicide in physicians versus other professionals. Mortality in physicians was used as a reference.

RESULTS

The lowest MRR for causes amenable to medical care was observed in engineers/architects (men: 0.84, 95% confidence interval [CI] 0.72, 0.97; women: 0.93, 95% CI 0.64, 1.35) and healthcare professions other than physicians/pharmacists/nurses (men: 0.86, 95% CI 0.56, 1.34; women: 0.69, 95% CI 0.32, 1.46). Regarding mortality for all other causes of death, professionals from these and other occupations presented lower mortality than physicians. Other healthcare professions, entrepreneurs, and managers/executives completed suicide at a higher rate than physicians.

CONCLUSION

Although the accessibility to the healthcare system and to the pharmacological drugs could suggest that physicians would present low rates for causes amenable to medical care and high rates of suicide, our results show that this is not the case in Spain.

Trends in socioeconomic inequalities in premature and avoidable mortality in Canada, 1991-2016

BACKGROUND

Recent epidemiologic findings suggest that socioeconomic inequalities in health may be widening over time. We examined trends in socioeconomic inequalities in premature and avoidable mortality in Canada.

METHODS

We conducted a population-based repeated cohort study using the 1991, 1996, 2001, 2006 and 2011 Canadian Census Health and Environment Cohorts. We linked individual-level Census records for adults aged 25-74 years to register-based mortality data. We defined premature mortality as death before age 75 years. For each census cohort, we estimated age-standardized rates, risk differences and risk ratios for premature and avoidable mortality by level of household income and education.

RESULTS

We identified 16 284 045 Census records. Between 1991 and 2016, premature mortality rates declined in all socioeconomic groups except for women without a high school diploma. Absolute income-related inequalities narrowed among men (from 2478 to 1915 deaths per 100 000) and widened among women (from 1008 to 1085 deaths per 100 000). Absolute education-related inequalities widened among men and women. Relative socioeconomic inequalities in premature mortality widened progressively over the study period. For example, the relative risk of premature mortality associated with the lowest income quintile increased from 2.10 (95% confidence interval [CI] 2.02-2.17) to 2.79 (95% CI 2.66-2.91) among men and from 1.72 (95% CI 1.63- 1.81) to 2.50 (95% CI 2.36-2.64) among women. Similar overall trends were observed for avoidable mortality.

INTERPRETATION

Socioeconomically disadvantaged groups have not benefited equally from recent declines in premature and avoidable mortality in Canada. Efforts to reduce socioeconomic inequalities and associated patterns of disadvantage are necessary to prevent this pattern of widening health inequalities from persisting or worsening over time.

Investigating the Geographic Disparities of Amenable Mortality and Related Ambulance Services in Hungary

The aim of this study was to investigate how amenable mortality and related ambulance services differ on a county level in Hungary. The differences in mortality rates and ambulance services could identify counties where stronger ambulance services are needed. The datasets for 2018 consisted of county level aggregated data of citizens between the ages 15–64. The study examined how both the mortality rates and the ambulance rescue deliveries differ from the national average. The analyses were narrowed down to disease groups, such as acute myocardial infarction, hemorrhagic and ischemic stroke. Inequalities were identified regarding the distribution of number of ambulance deliveries, several counties had rates more than double that of the national average. For both mortality and ambulance services some of the counties had significantly better results and others had significantly worse compared to the national average. In Borsod-Abaúj-Zemplén county’s case, hemorrhagic stroke mortality was significantly higher (1.73 [1.35–2.11]), while ambulance deliveries were significantly lower (0.58 [0.40–0.76]) compared to the national average. The research has shown that regarding the investigated mortality rates and ambulance services there are considerable differences between the counties in Hungary. In this regard policy makers should implement policies to tackle these discrepancies.

Social policies and change in education-related disparities in mortality in Japan, 2000-2010

Persistent socioeconomic disparity in mortality is a widely observed phenomenon despite improvements in the economic standard of living and the prevailing universal healthcare coverage policy. In this study, we selected Japan as a case in which public universal coverage has maintained horizontal equity in healthcare access while demographic and economic challenges have affected the life chances of vulnerable subpopulations over the past decade. We assessed the changing trends in the education-related disparity in mortality over a decade across demographic subpopulations for different causes of death, with the goal of generating social policy lessons to contribute to closing the mortality gap. Using a deterministic data merge between nationwide census and death records, we estimated age- and sex-specific mortality rates for 14 causes and their education-related gradients with absolute and relative indices of inequality in 2000 and 2010 via Poisson regression. Estimation parameters were standardized to the age structure of the sub-population of high school graduates in 2000 as the reference. The results demonstrated that the relative gaps in all-cause mortality persisted despite a decrease in the average mortality rate over the study period. The absolute gaps in mortality increased for preventable causes of death associated with lifestyle behavior choices. The average mortality worsened among socioeconomically vulnerable populations such as youth and women, who were left behind in the existing social/economic policy. External causes of death such as suicide and traffic accidents showed decreasing absolute gaps in a subpopulation targeted by universal social and labor policy measures. These change patterns indicate that, compared with a high-risk approach, a universal policy approach to dealing with societal and fundamental causes of health inequality seems more effective in reducing the education-related mortality gap in both absolute and relative terms.

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Socioeconomic gaps in mortality persist despite extended healthcare coverage.

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Education-related mortality gaps were confirmed in 2000 and 2010 in Japan.

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Relative inequality in preventable diseases increased under checkup-for-all policy.

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Youth and women, left behind in the current social policy, faced worsened gaps.

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Mortality gaps decreased when a universal policy on societal causes was adopted.

Death by austerity? The impact of cost containment on avoidable mortality in Italy

Does austerity in health care affect health and healthcare outcomes? We examine the intended and unintended effects of the Italian austerity policy Piano di Rientro aimed at containing the cost of the healthcare sector. Using an instrumental variable strategy that exploits the temporal and geographical variation induced by the policy rollout, we find that the policy was successful in alleviating deficits by reducing expenditure, mainly in the southern regions, but also resulted in a 3% rise in avoidable deaths among both men and women, a reduction in hospital capacity and a rise in south-to-north patient migration. These findings suggest that-even in a high-income country with relatively low avoidable mortality like Italy-spending cuts can hurt survival.

Changes in Socioeconomic Inequalities in Amenable Mortality after the Economic Crisis in Cities of the Spanish Mediterranean Coast

Several studies have described a decreasing trend in amenable mortality, as well as the existence of socioeconomic inequalities that affect it. However, their evolution, particularly in small urban areas, has largely been overlooked. The aim of this study is to analyse the socioeconomic inequalities in amenable mortality in three cities of the Valencian Community, namely, Alicante, Castellon, and Valencia, as well as their evolution before and after the start of the economic crisis (2000-2007 and 2008-2015). The units of analysis have been the census tracts and a deprivation index has been calculated to classify them according to their level of socioeconomic deprivation. Deaths and population were also grouped by sex, age group, period, and five levels of deprivation. The specific rates by sex, age group, deprivation level, and period were calculated for the total number of deaths due to all causes and amenable mortality and Poisson regression models were adjusted in order to estimate the relative risk. This study confirms that the inequalities between areas of greater and lesser deprivation in both all-cause mortality and amenable mortality persisted along the two study periods in the three cities. It also shows that these inequalities appear with greater risk of death in the areas of greatest deprivation, although not uniformly. In general, the risks of death from all causes and amenable mortality have decreased significantly from one period to the other, although not in all the groups studied. The evolution of death risks from before the onset of the crisis to the period after presented, overall, a general pro-cyclical trend. However, there are population subgroups for which the trend was counter-cyclical. The use of the deprivation index has made it possible to identify specific geographical areas with vulnerable populations in all three cities and, at the same time, to identify the change in the level of deprivation (ascending or descending) of the geographical areas throughout the two periods. It is precisely these areas where more attention is needed in order to reduce inequalities.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

Persisting inequalities in birth outcomes related to neighbourhood deprivation

INTRODUCTION

Health inequalities can be observed in early life as unfavourable birth outcomes. Evidence indicates that neighbourhood socioeconomic circumstances influence health. However, studies looking into temporal trends in inequalities in birth outcomes including neighbourhood socioeconomic conditions are scarce. The aim of this work was to study how inequalities in three different key birth outcomes have changed over time across different strata of neighbourhood deprivation.

METHODS

Nationwide time trends ecological study with area-level deprivation in quintiles as exposure. The study population consisted of registered singleton births in the Netherlands 2003-2017 between 24 and 41 weeks of gestation. Outcomes used were perinatal mortality, premature birth and small for gestational age (SGA). Absolute rates for all birth outcomes were calculated per deprivation quintile. Time trends in birth outcomes were examined using logistic regression models. To investigate relative inequalities, rate ratios for all outcomes were calculated per deprivation quintile.

RESULTS

The prevalence of all unfavourable birth outcomes decreased over time: from 7.2 to 4.1 per 1000 births for perinatal mortality, from 61.8 to 55.6 for premature birth, and from 121.9 to 109.2 for SGA. Inequalities in all birth outcomes have decreased in absolute terms, and the decline was largest in the most deprived quintile. Time trend analyses confirmed the overall decreasing time trends for all outcomes, which were significantly steeper for the most deprived quintile. In relative terms however, inequalities remained fairly constant.

CONCLUSION

In absolute terms, inequalities in birth outcomes by neighbourhood deprivation in the Netherlands decreased between 2003 and 2017. However, relative inequalities remained persistent.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

Progress against inequalities in mortality: register-based study of 15 European countries between 1990 and 2015

Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., 'relative' and 'absolute' inequalities, inequalities in 'attainment' and 'shortfall'). We determined which causes of death contributed to narrowing of inequalities, and conducted country- and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.

Measuring Health Vulnerability: An Interdisciplinary Indicator Applied to Mainland Portugal

Health promotion and inequality reduction are specific goals of the United Nations 2030 Agenda, which are interconnected with several dimensions of life. This work proposes a composite index SEHVI-socioeconomic health vulnerability index-to address Portuguese population socioeconomic determinants that affect health outcomes. Variables composing SEHVI are aligned with the sustainable development goals considering data and times series availability to enable progress monitoring, and variables adequacy to translate populations' life conditions affecting health outcomes. Data for 35 variables and three periods were collected from official national databases. All variables are part of one of the groups: Health determinants (social, economic, cultural, and environmental factors) and health outcomes (mortality indicators). Variables were standardized and normalized by "Distance to a reference" method and then aggregated into the SEHVI formula. Several statistical procedures for validation of SEHVI revealed the internal consistency of the index. For all municipalities, SEHVI was calculated and cartographically represented. Results were analyzed by statistical tests and compared for three years and territory typologies. SEHVI differences were found as a function of population density, suggesting inequalities of communities' life conditions and in vulnerability to health.

Progress in reducing inequalities in cardiovascular disease mortality in Europe

OBJECTIVE

To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe.

METHODS

In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities.

RESULTS

Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries.

CONCLUSIONS

Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

Avoidable, amenable, and preventable mortalities in South Korea, 2000-2017: Age-period-cohort trends and impact on life expectancy at birth

This study aimed to estimate age-period-cohort effects on avoidable mortality and quantify the impact of avoidable mortality changes on life expectancy (LE) at birth in the South Korean population aged 0-74 years. Using death certificate and resident population data from 2000 to 2017, trends in age-standardized avoidable mortality rates were analyzed with joinpoint regression. Intrinsic estimator regression analysis was conducted to estimate age-period-cohort effects on avoidable mortality. Arriaga's method was used to measure the contributions of avoidable causes to changes in LE gaps between adjacent three-year periods by age and avoidable cause of death groups. Avoidable mortality decreased annually by 4.6% between 2000 and 2017. There were strong age and cohort effects and a weak period effect on avoidable mortality. In the overall decreasing trend, avoidable mortality declined less in cohorts born after the 1950-1953 Korean War and economic recession in the 1970s, with further reductions in cohorts born after the 1987 democratic reform and 1997-1998 economic crisis. Avoidable mortality was reduced after implementation of major health policies, but the decrease stagnated during the 2008-2009 financial crisis. Avoidable mortality reduction resulted in LE gains of 3.1 years, which accounted for 80% of total LE gains. Contribution to LE gains by causes of death was the largest for cerebrovascular disease. Major social changes and health policies influenced the avoidable mortality trend through cohort and period effects. Health care and public health policies implemented since the 2000s might have contributed substantially to gains in LE.

Use of out-of-hours primary care in affluent and deprived neighbourhoods during reforms in long-term care: an observational study from 2013 to 2016

OBJECTIVES

Major long-term care (LTC) reforms in the Netherlands in 2015 may specifically have disadvantaged socioeconomically deprived groups to acquire LTC, possibly impacting the use of acute care. We aimed to demonstrate whether LTC reforms coincided with changes in the use of out-of-hours (OOH) primary care services (PCSs), and to compare changes between deprived versus affluent neighbourhoods.

DESIGN

Ecological observational retrospective study using routinely recorded electronic health records data from 2013 to 2016 and population registry data.

SETTING

Data from 15 OOH PCSs participating in the Nivel Primary Care Database (covering approximately 6.5 million inhabitants) in the Netherlands. PCS utilisation data on neighbourhood level were matched with sociodemographic characteristics, including neighbourhood socioeconomic status (SES).

PARTICIPANTS

Electronic health records from 6 120 384 OOH PCS contacts in 2013-2016, aggregated to neighbourhood level.

OUTCOME MEASURES AND ANALYSES

Number of contacts per 1000 inhabitants/year (total, high/low-urgency, night/evening-weekend-holidays, telephone consultations/consultations/home visits).Multilevel linear regression models included neighbourhood (first level), nested within PCS catchment area (second level), to account for between-PCS variation, adjusted for neighbourhood characteristics (for instance: % men/women). Difference-in-difference in time-trends according to neighbourhood SES was assessed with addition of an interaction term to the analysis (year×neighbourhood SES).

RESULTS

Between 2013 and 2016, overall OOH PCS use increased by 6%. Significant increases were observed for high-urgency contacts and contacts during the night. The largest change was observed for the most deprived neighbourhoods (10% compared with 4%-6% in the other neighbourhoods; difference not statistically significant). The increasing trend in OOH PCS use developed practically similar for deprived and affluent neighbourhoods. A a stable gradient reflected more OOH PCS use for each lower stratum of SES.

CONCLUSIONS

LTC reforms coincided with an overall increase in OOH PCS use, with nearly similar trends for deprived and affluent neighbourhoods. The results suggest a generalised spill over to OOH PCS following LTC reforms.

Socioeconomic status and 30-day mortality after minor and major trauma: A retrospective analysis of the Trauma Audit and Research Network (TARN) dataset for England

INTRODUCTION

Socioeconomic status (SES) is associated with rate and severity of trauma. However, it is unclear whether there is an independent association between SES and mortality after injury. Our aim was to assess the relationship between SES and mortality from trauma.

MATERIALS AND METHODS

We conducted a secondary analysis of the Trauma Audit and Research Network dataset. Participants were patients admitted to NHS hospitals for trauma between January 2015 and December 2015, and resident in England. Analyses used multivariate logistic regression with thirty-day mortality as the main outcome. Co-variates include SES derived from area-level deprivation, age, injury severity and comorbidity. All analyses were stratified into minor and major trauma.

RESULTS

There were 48,652 admissions (68% for minor injury, ISS<15) included, and 3,792 deaths. Thirty-day mortality was 10% for patients over 85 with minor trauma, which was higher than major trauma for all age groups under 65. Deprivation was not significantly associated with major trauma mortality. For minor trauma, patients older than 40 had significantly higher aORs than the 0-15 age group. Both the most and second most deprived had significantly higher aORs (1.35 and 1.28 respectively).

CONCLUSIONS

This study provides evidence of an independent relationship between SES and mortality after minor trauma, but not for major trauma. Our results identify that, for less severe trauma, older patients and patients with low SES with have an increased risk of 30-day mortality. Policy makers and service providers should consider extending the provision of 'major trauma' healthcare delivery to this at-risk population.

Trends of socioeconomic equality in mortality amenable to healthcare and health policy in 1992-2013 in Finland: a population-based register study

OBJECTIVE

To study trends in socioeconomic equality in mortality amenable to healthcare and health policy interventions.

DESIGN

A population-based register study.

SETTING

Nationwide data on mortality from the Causes of Death statistics for the years 1992-2013.

PARTICIPANTS

All deaths of Finnish inhabitants aged 25-74.

OUTCOME MEASURES

Yearly age-standardised rates of mortality amenable to healthcare interventions, alcohol-related mortality, ischaemic heart disease mortality and mortality due to all the other causes by income. Concentration index (C) was used to evaluate the magnitude and changes in income group differences.

RESULTS

Significant socioeconomic inequalities favouring the better-off were observed in each mortality category among younger (25-64) and older (65-74) age groups. Inequality was highest in alcohol-related mortality, C was -0.58 (95% CI -0.62 to -0.54) among younger men in 2008 and -0.62 (-0.72 to -0.53) among younger women in 2013. Socioeconomic inequality increased significantly during the study period except for alcohol-related mortality among older women.

CONCLUSIONS

The increase in socioeconomic inequality in mortality amenable to healthcare and health policy interventions between 1992 and 2013 suggests that either the means or the implementation of the health policies have been inadequate.

The Portuguese version of the European Deprivation Index: Development and association with all-cause mortality

Socioeconomic inequalities are major health determinants. To monitor and understand them at local level, ecological indexes of socioeconomic deprivation constitute essential tools. In this study, we describe the development of the updated version of the European Deprivation Index for Portuguese small-areas (EDI-PT), describe its spatial distribution and evaluate its association with a general health indicator–all-cause mortality in the period 2009–2012. Using data from the 2011 European Union–Statistics on Income and Living Conditions Survey (EU-SILC), we obtained an indicator of individual deprivation. After identifying variables that were common to both the EU-SILC and the census, we used the indicator of individual deprivation to test if these variables were associated with individual-level deprivation, and to compute weights. Accordingly, eight variables were included. The EDI-PT was produced for the smallest area unit possible (n = 18084 census block groups, mean/area = 584 inhabitants) and resulted from the weighted sum of the eight selected variables. It was then categorized into quintiles (Q1-least deprived to Q5-most deprived). To estimate the association with mortality we fitted Bayesian spatial models. The EDI-PT was unevenly distributed across Portugal–most deprived areas concentrated in the South and in the inner North and Centre of the country, and the least deprived in the coastal North and Centre. The EDI-PT was positively and significantly associated with overall mortality, and this relation followed a rather clear dose-response relation of increasing mortality as deprivation increases (Relative Risk Q2 = 1.012, 95% Credible Interval 0.991–1.033; Q3 = 1.026, 1.004–1.048; Q4 = 1.053, 1.029–1.077; Q5 = 1.068, 1.042–1.095). Summing up, we updated the index of socioeconomic deprivation for Portuguese small-areas, and we showed that the EDI-PT constitutes a sensitive measure to capture health inequalities, since it was consistently associated with a key measure of population health/development, all-cause mortality. We strongly believe this updated version will be widely employed by social and medical researchers and regional planners.

Evaluating effects of recent changes in NHS resource allocation policy on inequalities in amenable mortality in England, 2007-2014: time-series analysis

BACKGROUND

Health investment in England post-2010 has increased at lower rates than previously, with proportionally less being allocated to deprived areas. This study seeks to explore the impact of this on inequalities in amenable mortality between local areas.

METHODS

We undertook a time-series analysis across 324 lower-tier local authorities in England, evaluating the impact of changes in funding allocations to health commissioners from 2007 to 2014 on spatial inequalities in age-standardised under-75 mortality rates for conditions amenable to healthcare for men and women, adjusting for trends in household income, unemployment and time-trends.

RESULTS

More deprived areas received proportionally more funding between 2007 and 2014, though the reorganisation of commissioning in 2012 stalled this. Funding increases to more deprived local areas accounted for a statistically significant reduction in inequalities in male amenable mortality between local areas of 13 deaths per 100 000 (95% CI 2.5 to 25.9). Funding changes were associated with a reduction in inequalities in female amenable mortality of 7.0 per 100,000, though this finding did not reach significance (p=0.09).

CONCLUSION

Current National Health Service (NHS) resource allocation policy in England appears to be contributing to a convergence in health outcomes between affluent and deprived areas. However, careful surveillance is needed to evaluate whether diminished allocations to more deprived areas in recent years and reduced NHS investment as a whole is impacting adversely on inequalities between groups.

Education, sex and risk of stroke: a prospective cohort study in New South Wales, Australia

OBJECTIVE

To determine whether the association between highest educational attainment and stroke differed by sex and age; and whether potential mediators of observed associations differ by sex.

DESIGN

Prospective cohort study.

SETTING

Population based, New South Wales, Australia.

PARTICIPANTS

253 657 stroke-free participants from the New South Wales 45 and Up Study.

OUTCOME MEASURES

First-ever stroke events, identified through linkage to hospital and mortality records.

RESULTS

During mean follow-up of 4.7 years, 2031 and 1528 strokes occurred among men and women, respectively. Age-standardised stroke rate was inversely associated with education level, with the absolute risk difference between the lowest and highest education group greater among women than men. In relative terms, stroke risk was slightly more pronounced in women than men when comparing low versus high education (age-adjusted HRs: 1.41, 95% CI 1.16 to 1.71 and 1.25, 95% CI 1.07 to 1.46, respectively), but there was no clear evidence of statistical interaction. This association persisted into older age, but attenuated. Much of the increased stroke risk was explained by modifiable lifestyle factors, in both men and women.

CONCLUSION

Low education is associated with increased stroke risk in men and women, and may be marginally steeper in women than men. This disadvantage attenuates but persists into older age, particularly for women. Modifiable risk factors account for much of the excess risk from low education level. Public health policy and governmental decision-making should reflect the importance of education, for both men and women, for positive health throughout the life course.

Trends in health inequalities in 27 European countries

Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from ca 1980 to ca 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from ca 2002 to ca 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016

BACKGROUND

A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.

METHODS

Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita.

FINDINGS

In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries.

INTERPRETATION

GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.

FUNDING

Bill & Melinda Gates Foundation.

Does community deprivation determine longevity after the age of 75? A cross-national analysis

OBJECTIVES

Analyze the association between socioeconomic deprivation and old-age survival in Europe, and investigate whether it varies by country and gender.

METHODS

Our study incorporated five countries (Portugal, Spain, France, Italy, and England). A 10-year survival rate expressing the proportion of population aged 75-84 years who reached 85-94 years old was calculated at area-level for 2001-11. To estimate associations, we used Bayesian spatial models and a transnational measure of deprivation. Attributable/prevention fractions were calculated.

RESULTS

Overall, there was a significant association between deprivation and survival in both genders. In England that association was stronger, following a dose-response relation. Although lesser in magnitude, significant associations were observed in Spain and Italy, whereas in France and Portugal these were even weaker. The elimination of socioeconomic differences between areas would increase survival by 7.1%, and even a small reduction in socioeconomic differences would lead to a 1.6% increase.

CONCLUSIONS

Socioeconomic deprivation was associated with survival among older adults at ecological-level, although with varying magnitude across countries. Reasons for such cross-country differences should be sought. Our results emphasize the importance of reducing socioeconomic differences between areas.