Cookson Richard, Gutacker Nils, Garcia-Armesto Sandra, Angulo-Pueyo Ester, Christiansen Terkel, Bloor Karen, Bernal-Delgado Enrique
1 Centre for Health Economics, University of York, York, UK
1 Centre for Health Economics, University of York, York, UK.
Eur J Public Health. 2015 Feb;25 Suppl 1:21-7. doi: 10.1093/eurpub/cku220.
Cross-country comparisons of socioeconomic equity in health care typically use sample survey data on general services such as physician visits. This study uses comprehensive administrative data on a specific service: hip replacement.
We analyse 651 652 publicly funded hip replacements, excluding fractures and accidents, in adults over 35 in Denmark, England, Portugal and Spain from 2002 to 2009. Sub-national administrative areas are split into socioeconomic quintile groups comprising approximately one-fifth of the national population. Area-level Poisson regression with Huber-White standard errors is used to calculate age-sex standardised hip replacement rates by quintile group, together with gaps and ratios between richest and poorest groups (Q5 and Q1) and the middle group (Q3).
We find pro-rich-area inequality in England (2009 Q5/Q1 ratio 1.35 [CI 1.25-1.45]) and Spain (2009 Q5/Q1 ratio 1.43 [CI 1.17-1.70]), pro-poor-area inequality in Portugal (2009 Q5/Q1 ratio 0.67 [CI 0.50-0.83]) and no significant inequality in Denmark. Pro-rich-area inequality increased over time in England and Spain but not significantly. Within-country differences between socioeconomic quintile groups are smaller than between-country differences in general population averages: hip replacement rates are substantially lower in Portugal and Spain (8.6 and 7.4 per 10 000 in 2009) than England and Denmark (20.2 and 27.8 per 10 000 in 2009).
Despite limitations regarding individual-level inequality and area heterogeneity, analysis of area-level data on publicly funded hospital activity can provide useful cross-country comparisons and longitudinal monitoring of socioeconomic inequality in specific health services. Although this kind of analysis cannot provide definitive answers, it can raise important questions for decision makers.
医疗保健领域社会经济公平性的跨国比较通常使用关于诸如就诊等一般服务的抽样调查数据。本研究使用了关于一项特定服务——髋关节置换术的综合行政数据。
我们分析了2002年至2009年丹麦、英格兰、葡萄牙和西班牙35岁以上成年人中651652例由公共资金资助的髋关节置换术（不包括骨折和事故导致的置换）。国家以下行政区域被划分为社会经济五分位数组，每组约占全国人口的五分之一。使用带有稳健标准误的区域层面泊松回归，按五分位数组计算年龄 - 性别标准化髋关节置换率，以及最富有组和最贫困组（Q5和Q1）与中间组（Q3）之间的差距和比率。
我们发现，在英格兰（2009年Q5/Q1比率为1.35 [可信区间1.25 - 1.45]）和西班牙（2009年Q5/Q1比率为1.43 [可信区间1.17 - 1.70]）存在有利于富裕地区的不平等，在葡萄牙存在有利于贫困地区的不平等（2009年Q5/Q1比率为0.67 [可信区间0.50 - 0.83]），而在丹麦没有显著不平等。在英格兰和西班牙，有利于富裕地区的不平等随时间增加，但不显著。社会经济五分位数组内的国家差异小于总体人口平均值的国家间差异：葡萄牙和西班牙的髋关节置换率（2009年每10000人分别为8.6例和7.4例）显著低于英格兰和丹麦（2009年每10000人分别为20.2例和27.8例）。
尽管在个体层面不平等和区域异质性方面存在局限性，但对公共资金资助的医院活动的区域层面数据分析可为特定医疗服务的社会经济不平等提供有用的跨国比较和纵向监测。虽然这种分析不能提供确凿答案，但可为决策者提出重要问题。
