Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.
Network of Academic Health Centres and Department of General Practice and Primary Health Care, University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland.
BMC Health Serv Res. 2023 Aug 7;23(1):835. doi: 10.1186/s12913-023-09855-0.
Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance.
We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities.
Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment.
While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.
丹麦、芬兰和瑞典通过全民医疗保健为其公民追求健康公平。然而，目前尚不清楚这些服务在不同的社会经济地位或居住地区是否平等惠及老年人群体。因此，我们评估了丹麦首都地区（哥本哈根）、芬兰首都地区（赫尔辛基）和瑞典首都地区（斯德哥尔摩）的老年人初级保健（PHC）绩效的地理和社会经济公平性，时间范围为 2000-2015 年。将门诊治疗敏感条件（ACSC）的住院治疗作为 PHC 绩效的替代指标。
我们从国家住院登记处获取了 2000-2015 年间年龄在 45 岁及以上的个体的 ACSC 数据。为了确定差异是否因年龄而异，我们应用了三个年龄组（45-64 岁、65-75 岁和≥75 岁）。通过教育、收入和独居情况的发病率比值（IRR）和年度比率来描述 ACSC 的社会经济差异，然后通过收入的两年期集中指数进行分析。通过小区域的两年期 ACSC 率描述地理差异，并通过两级泊松多水平模型进行分析。这些模型为 2000 年 ACSC 的小区域估计值及其随时间发展的斜率提供了估计值，在每个首都地区内计算了这些斜率之间的皮尔逊相关系数。最后，对这些模型进行了收入调整，以区分地理和社会经济差异。
在 45-64 岁年龄组中，哥本哈根的 ACSC IRR 最高，在≥75 岁年龄组中，赫尔辛基的 ACSC IRR 最高。随着时间的推移，所有年龄组的 IRR 都有所下降，但在≥75 岁年龄组中，只有赫尔辛基的 IRR 下降。所有集中指数都略微有利于富裕人群，但在斯德哥尔摩主要不显著。在≥75 岁年龄组中，哥本哈根的皮尔逊相关系数较低（-0.14；p=0.424），但在赫尔辛基（-0.74；<0.001）和斯德哥尔摩（-0.62；<0.001）的相关系数较低 - 收入调整后相关性略有变化。在≥45 岁年龄组中，除了哥本哈根的相关系数较强（-0.51，0.001）外，其他相关系数都相当相似。
虽然在三个北欧首都地区的老年人群体中，PHC 绩效的社会经济差异仍然存在，但在赫尔辛基和斯德哥尔摩，地理差异有所缩小，但在哥本哈根仍然存在。我们的研究结果表明，丹麦的初级卫生保健在一定程度上减轻了社会经济隔离的负面影响。
