The effects of socioeconomic status, accessibility to services and patient type on hospital use in Western Australia: a retrospective cohort study of patients with homogenous health status

BACKGROUND: This study aimed to investigate groups of patients with a relatively homogenous health status to evaluate the degree to which use of the Australian hospital system is affected by socio-economic status, locational accessibility to services and patient payment classification. METHOD: Records of all deaths occurring in Western Australia from 1997 to 2000 inclusive were extracted from the WA mortality register and linked to records from the hospital morbidity data system (HMDS) via the WA Data Linkage System. Adjusted incidence rate ratios of hospitalisation in the last, second and third years prior to death were modelled separately for five underlying causes of death. RESULTS: The independent effects of socioeconomic status on hospital utilisation differed markedly across cause of death. Locational accessibility was generally not an independent predictor of utilisation except in those dying from ischaemic heart disease and lung cancer. Private patient status did not globally affect utilisation across all causes of death, but was associated with significantly decreased utilisation three years prior to death for those who died of colorectal, lung or breast cancer, and increased utilisation in the last year of life in those who died of colorectal cancer or cerebrovascular disease. CONCLUSION: It appears that the Australian hospital system may not be equitable since equal need did not equate to equal utilisation. Further it would appear that horizontal equity, as measured by equal utilisation for equal need, varies by disease. This implies that a 'one-size-fits-all' approach to further improvements in equity may be over simplistic. Thus initiatives beyond Medicare should be devised and evaluated in relation to specific areas of service provision

Increasing socioeconomic inequalities in first acute myocardial infarction in Scotland, 1990–92 and 2000–02

<p>Background: Despite substantial declines, Ischaemic Heart Disease (IHD) remains the largest cause of death in Scotland and mortality rates are among the worst in Europe. There is evidence of strong, persisting regional and socioeconomic inequalities in IHD mortality, with the majority of such deaths being due to Acute Myocardial Infarction (AMI). We examine the changes in socioeconomic and geographic inequalities in first AMI events in Scotland and their interactions with age and gender.</p> <p>Methods: We used linked hospital discharge and death records covering the Scottish Population (5.1 million). Risk ratios (RR) of AMI incidence by area deprivation and age for men and women were estimated using multilevel Poisson modelling. Directly standardised rates were presented within these stratifications.</p> <p>Results: During 1990–92 74,213 people had a first AMI event and 56,995 in 2000–02. Adjusting for area deprivation accounted for 59% of the geographic variability in AMI incidence rates in 1990–92 and 33% in 2000–02. Geographic inequalities in male incidence reduced; RR for smaller areas (comparing area on 97.5th centile to 2.5th) reduced from 1.42 to 1.19. This was not true for women; RR increased from 1.45 to 1.59. The socioeconomic gradient in AMI incidence increased over time (p-value < 0.001) but this varied by age and gender. The gradient across deprivation categories for male incidence in 1990–92 was most pronounced at younger ages; RR of AMI in the most deprived areas compared to the least was 2.6 (95% CI: 1.6–4.3) for those aged 45–59 years and 1.6 (1.1–2.5) at 60–74 years. This association was also evident in women with even stronger socioeconomic gradients; RRs for these age groups were 4.4 (3.4–5.5), and 1.9 (1.7–2.2). Inequalities increased by 2000–02 for both sexes; RR for men aged 45–59 years was 3.3 (3.0–3.6) and for women was 5.6 (4.1–7.7)</p> <p>Conclusion: Relative socioeconomic inequalities in AMI incidence have increased and gradients are steepest in young women. The geographical patterning of AMI incidence cannot be fully explained by socioeconomic deprivation. The reduction of inequalities in AMI incidence is key to reducing overall inequalities in mortality and must be a priority if Scotland is to achieve its health potential.</p&gt

Exploring controls of the early and stepped deglaciation on the western margin of the British Irish Ice Sheet

New optically stimulated luminescence dating and Bayesian models integrating all legacy and BRITICE-CHRONO geochronology facilitated exploration of the controls on the deglaciation of two former sectors of the British–Irish Ice Sheet, the Donegal Bay (DBIS) and Malin Sea ice-streams (MSIS). Shelf-edge glaciation occurred ~27 ka, before the global Last Glacial Maximum, and shelf-wide retreat began 26–26.5 ka at a rate of ~18.7–20.7 m a–1. MSIS grounding zone wedges and DBIS recessional moraines show episodic retreat punctuated by prolonged still-stands. By ~23–22 ka the outer shelf (~25 000 km2) was free of grounded ice. After this time, MSIS retreat was faster (~20 m a–1 vs. ~2–6 m a–1 of DBIS). Separation of Irish and Scottish ice sources occurred ~20–19.5 ka, leaving an autonomous Donegal ice dome. Inner Malin shelf deglaciation followed the submarine troughs reaching the Hebridean coast ~19 ka. DBIS retreat formed the extensive complex of moraines in outer Donegal Bay at 20.5–19 ka. DBIS retreated on land by ~17–16 ka. Isolated ice caps in Scotland and Ireland persisted until ~14.5 ka. Early retreat of this marine-terminating margin is best explained by local ice loading increasing water depths and promoting calving ice losses rather than by changes in global temperatures. Topographical controls governed the differences between the ice-stream retreat from mid-shelf to the coast