1. Socioeconomic differences in the utilisation of health care services: a European overview Anton Kunst for the international seminar on socioeconomic differences in health care utilisation Brussels, 30 October 2008

2. How large inequalities could be: poor-rich differences in child health care in Turkey, 1990s

3. Contents 1.Health care and health 2.Need and use of care 3.Use and accessibility of care 4.Quality of care 5.Health care programs and policies

4. Source of illustrations  European overviews: from the Eurothine project  data from national mortality registries, national interview surveys, or the SHARE baseline survey  publications by Johan Mackenbach, Anton Kunst, Irina Stirbu et al  www.eurothine.org  National illustrations: from published reports and papers

5. Health and health care (1)  Key message in Europe, inequalities also exist in health problems that are potentially amenable to medical intervention

6. Health and health care (2) Educational difference in number of days lived between 35 th and 70 th birthday, 1990s

7. Health and health care (2b) Idem, including eastern European countries

8. Health and health care (3) Specific “avoidable” causes of death The magnitude of educational inequalities in mortality from nine causes of death (men and women 30-64 years; 16 countries) Tuberculosis = 14.68 Pneumonia = 5.46 Leukemia = 1.32 Cervix cancer = 3.90 Stroke, hypertension = 3.30 Rheumatic heart dis= 3.54 Asthma = 4.50 Cholecistitis= 3.62 Appendicitis etc= 4.63

9. Health and health care (4) Cancer survival in the Netherlands, 1990s

10. Need and use (1)  Key message in Europe, differences in the utilization of most health services are according to need, except for use of specialist visits

11. Need and use (2) Differences in volume of use of several types of services  Rate ratios comparing lower to higher income groups for total volume of use of different services, Netherlands, 2003  GP visits = 1.57 Specialist visits = 1.35  Physiotherapist= 1.19 Dentist visits= 0.91  Hospital nights= 2.07 Prescribed medicines= 1.37  Mental health care= 7.01 Social work= 5.08  Family nurse= 4.02 Alternative medicine= 0.75

12. Need and use (3) Most differences are according to need Educational differences in utilisation of four services before and after control for health status

13. Need and use (4) Difference of low vs. high educated groups in frequency of GP visits, early 2000’s

14. Need and use (5) Difference of low vs. high educated groups in frequency of visits to the specialist

15. Use and accessibility of care (1)  Key message Lower socioeconomic groups face specific problems affecting use and accessibility of services

16. Use and access (2) Health care foregone because of costs or unavailability, by income level, 2004

17. Use and access (3) Summary of inequalities in the utilisation of preventive services, ca. 2004 Less than 10 percent difference Flu vaccination Cholesterol check Blood pressure control About 10 percent difference Breast cancer screening About 25 percent difference Eye examination Colon cancer screening

18. Use and access (4) Utilization of mammography by educational level, 2004

19. Quality of care (1)  Key message there is evidence for inequalities in quality of care delivered to patients from lower classes, at least for specialized services

20. Quality of care (2) Treatment of MI patients in Finland  Rate ratio comparing the chance of recieving invasive cardiac procedures within 2 years after myocardial infarction. Finland, men (women)  Low vs. intermediate/high education= 0.86 (0.90)  Blue collar vs. white collar= 0.76 (0.91)  Low vs. high income = 0.75 (0.57)

21. Quality of care (3) Treatment of heart patients in Dutch GP practices Rates of treatment for men according to educational level High/midLow - Diuretics and ACE inhibitors64.862.7% (for heart failure patients) - Aspirin 55.556.0% (for TIA, PAD and AP patients) - Specialist referral10.612.0% (for all patients groups above)

22. Quality of care (4) Experiences of patients with GP consults in Belgium “This literature review we found that patients from lower social classes receive:  significantly less positive socio-emotional utterances,  a more directive and a less participatory consulting style e.g. less involvement in treatment decisions;  lower patient control over communication;  less diagnostic and treatment information,  more physical examination.” (Willems et al, 2004)

23. Programs and policies (1)  Key message programs and policies can have different effects among different socioeconomic groups

24. Programs and policies (2) Invitation strategies for breast cancer screening Quiz. Reviews of intervention studies showed that organised breast cancer screening increase attendance among lower social groups in different ways, except by A: Promotion through primary care physicians C: Invitation letters with medical explanations B : Individual tailoring of invitation letters D : Removing financial constraints, e.g. fees

25. Programs and policies (3) Evaluation of smoking cessation services for deprived areas in England, early 2000’s SES (combination of education, housing tenure and living conditions) % of smokers making a quit attempt (1) % quitters successful after 1 year (2) % of all smokers who successfully quitted (1) * (2) Lowest 20%2,313,00,42 Next 20 %1,915,00,38 Mid 20%1,614,80,37 Next 20%1,518,80,47 Highest 20%1,316,90,17

26. Programs and policies (4) health care characteristics (un-)related to inequalities in specialist visits, 13 countries, ca. 2003 Related to smaller inequalities in specialist visits Tax-based health care systems Gate keeping by GP Less out-of-pocket payments Unrelated to the magnitude of inequalities Payment methods of physicians Public health expenditure (as % of GDP) Doctor availability

27. Summary 1.Inequalities exist for conditions amenable to medical intervention 2.Utilization of health services is generally according to need 3.Lower groups often do face specific problems with accessibility 4.Quality of care delivered to low-class patients is sometimes lower 5.Equity-oriented programs and policies can make a difference