Developing methodology of measuring socioeconomic equity in health care using register data

In most countries, the health care system aims to achieve equity as one of its primary goals. However, evident and persistent inequities in health care exist despite the improvement in the overall level of morbidity, health care performance and health care technology. This thesis develops statistical methods to evaluate socioeconomic equity in health care using register data. Moreover, this thesis provides information on socioeconomic equity in health care in Finland between 1992 and 2010 from several viewpoints. This thesis utilises two outcomes the use of coronary revascularisations and mortality amenable to health care interventions as empirical examples of the use of individual-level register data. Coronary revascularisation is a common invasive procedure and provides a good indication of health care system performance. Amenable mortality refers to causes of death that should be avoided in the presence of timely and effective health care interventions. It serves as an indirect measure of performance and the quality of health care. Data on revascularisations were obtained from the Care Register for Health Care and data on amenable deaths from the National Causes of Death statistics. These datasets were individually linked to population registers maintained by Statistics Finland to obtain sociodemographic data. This thesis develops a method to compare regional differences in socioeconomic equity in health care. The method takes dependence of observations within regions into account and its advantage is in overcoming the problems associated with random error in small regions. Additionally, it takes into account the effect of variation in the population size by age and socioeconomic position in regions in addition to different needs for health care. The existing methods measuring absolute differences do not provide solutions for evaluating absolute inequity in health care while taking the need for care into account. This thesis proposes a non-numerical approach to evaluating absolute horizontal socioeconomic equity in health care. Moreover, this study presents methods to assess uncertainty in the inequity indices when using register data. Evaluation of the uncertainty of the equity measures ensures that comparisons at different levels (between hospitals, areas, countries, in time) are meaningful. Finally, this thesis introduces an improved approach to studying socioeconomic equity in the effectiveness of health care. The approach uses amenable mortality as an indicator of health care performance and allows for an analysis of time trends in equity. Causes of deaths are assigned to categories according to the time and site of the interventions, which allows the indicative estimation of the effect of different sectors of health care systems on inequity. This study detected marked and persistent relative horizontal inequity in the use of revascularisations favouring the better-off in the period 1995 2010 in Finland. Contrary to earlier research, this study found no decrease in relative inequity. The results suggest that absolute horizontal inequity decreased although this cannot be quantified numerically. However, differences in inequity between regions were minor in 2001 2003, especially among men. The results of this study indicate that socioeconomic inequities in relative terms in deaths amenable to health care were marked and increased between 1992 and 2008 in Finland. Inequity was greater in deaths amenable to specialised health care, but the influence of primary health care on widening inequities was more substantial. In absolute terms, major socioeconomic inequity in amenable mortality remained. These results suggest that socioeconomic disparities in either access to or quality of health care in Finland did not diminish. The results of this thesis should prompt a serious consideration of actions to improve equity in health care in Finland.Useimmissa maissa terveydenhuoltojärjestelmän yksi keskeisimpiä tavoitteita on terveyspalveluiden oikeudenmukainen jakautuminen väestöryhmien välillä. Vaikka väestön yleinen terveydentila on parantunut sekä terveydenhuollon toimintakyky ja teknologia on huomattavasti kehittynyt viime vuosikymmeninä, palvelut jakaantuvat sosiaalisen aseman mukaan epäoikeudenmukaisesti. Tämän väitöskirjan tavoitteena on kehittää tilastollisia menetelmiä terveyspalveluiden käytön sosioekonomisen oikeudenmukaisuuden arviointiin. Väitöskirja antaa lisäksi tietoa monesta eri näkökulmasta terveydenhuollon oikeudenmukaisuuden tilasta Suomessa vuosien 1992 ja 2010 välillä. Tutkimukset perustuvat yksilötasoisiin rekisteriaineistoihin ja empiirisinä esimerkkeinä oikeudenmukaisuuden arvioinnissa käytetään sepelvaltimotautitoimenpiteitä sekä vältettävissä olevia kuolemia. Pallolaajennukset ja ohitusleikkaukset ovat yleisiä toimenpiteitä sepelvaltimotaudin hoidossa ja niiden käytön jakaumat tarjoavat hyvän esimerkin terveydenhuoltojärjestelmän toiminnasta. Vältettävissä olevilla kuolemilla tarkoitetaan kuolemia, joita ei pitäisi tapahtua, jos terveyspalvelut ovat vaikuttavia ja oikea-aikaisia. Niiden avulla voidaan epäsuorasti mitata terveydenhuollon toimintaa ja laatua. Tiedot sepelvaltimotautitoimenpiteistä saatiin terveydenhuollon hoitoilmoitusrekisteristä ja tiedot vältettävissä olevista kuolemista kuolemansyyrekisteristä. Nämä aineistot yhdistettiin Tilastokeskuksen rekistereihin, joista saatiin henkilöiden sosiodemografiset tiedot. Väitöskirja esittelee menetelmän, jonka avulla voidaan vertailla alueellisia eroja sosioekonomisessa oikeudenmukaisuudessa terveydenhuollossa. Metodi ottaa huomioon alueiden väliset riippuvuudet, sekä iän, sosioekonomisen aseman ja alueiden mukaan vaihtelevat hoidon tarpeet ja väestöryhmien koot. Menetelmän etuna on välttyä pienten alueiden satunnaisvaihtelun aiheuttamilta ongelmilta. Käytössä olevat menetelmät absoluuttisten erojen mittaamisessa eivät tarjoa ratkaisua absoluuttisen eriarvoisuuden arvioimiseen terveyspalveluiden käytössä suhteessa hoidon tarpeeseen. Tämä väitöskirja ehdottaa ei-numeerisen lähestymistavan absoluuttisen horisontaalisen (hoidon tarpeen huomioivan) sosioekonomisen oikeudenmukaisuuden arvioimiseksi. Lisäksi, tämä tutkimus kehittää tilastollisia menetelmiä oikeudenmukaisuusindeksien epävarmuuden estimoimiseksi kun aineistona käytetään rekistereitä. Indeksien epävarmuuden arvioiminen takaa, että vertailut eri tasoilla (sairaaloiden, alueiden ja maiden välillä, eri ajan hetkillä) ovat mielekkäitä. Lopuksi tämä väitöstutkimus esittelee kehittyneen tavan tutkia rekisteriaineistolla oikeudenmukaisuutta terveydenhuollon tehokkuudessa. Tämä lähestymistapa käyttää vältettävissä olevia kuolemia terveydenhuollon toiminnan indikaattorina ja sen avulla voidaan tutkia oikeudenmukaisuuden muutoksia ajassa. Kuolemansyyt on jaoteltu ryhmiin interventioiden ajankohdan ja paikan mukaan. Ryhmittelyn avulla pystytään arvioimaan terveydenhuollon eri sektoreiden vaikutukset oikeudenmukaisuuteen. Vuosina 1995 2010 Suomessa havaittiin huomattavaa, jatkuvaa ja hyvätuloisia suosivaa suhteellista horisontaalista epäoikeudenmukaisuutta sepelvaltimotautitoimenpiteissä. Aiempien tutkimusten tuloksista poiketen, suhteellinen epäoikeudenmukaisuus ei vähentynyt. Tulokset osoittavat kuitenkin, että absoluuttinen horisontaalinen epäoikeudenmukaisuus väheni vaikka sitä ei pystytä numeerisesti määrittämään. Alueiden väliset erot epäoikeudenmukaisuudessa olivat kuitenkin vähäisiä vuosina 2001 2003, erityisesti miehillä. Hyvätuloisia suosiva suhteellinen epäoikeudenmukaisuus vältettävissä olevissa kuolemissa oli huomattavaa ja kasvoi vuosien 1992 ja 2008 välillä Suomessa. Epäoikeudenmukaisuus oli suurempaa erikoissairaanhoidon keinoin vältettävissä olevissa kuolemissa, mutta perusterveydenhuollon vaikutus kasvaviin eroihin oli suurempi. Absoluuttisesti arvioituna epäoikeudenmukaisuus säilyi merkittävänä. Väitöskirjan tulokset viittaavat siihen, että sosioekonomiset erot terveydenhuollon laadussa ja hoitoon pääsyssä ovat Suomessa säilyneet. Oikeudenmukaisuuden parantamiseksi tulisi ryhtyä toimiin, joiden avulla voidaan turvata sosiaalisesti huonomassa asemassa olevien tarpeenmukainen hoito

Epidemiologisia tutkimusasetelmia syöpäriskin arvioinnissa biologisten näyteaineistojen avulla

Only abstract. Paper copies of master’s theses are listed in the Helka database (http://www.helsinki.fi/helka). Electronic copies of master’s theses are either available as open access or only on thesis terminals in the Helsinki University Library.Vain tiivistelmä. Sidottujen gradujen saatavuuden voit tarkistaa Helka-tietokannasta (http://www.helsinki.fi/helka). Digitaaliset gradut voivat olla luettavissa avoimesti verkossa tai rajoitetusti kirjaston opinnäytekioskeilla.Endast sammandrag. Inbundna avhandlingar kan sökas i Helka-databasen (http://www.helsinki.fi/helka). Elektroniska kopior av avhandlingar finns antingen öppet på nätet eller endast tillgängliga i bibliotekets avhandlingsterminaler.Tutkielman tarkoituksena on tutustua tilastollisiin menetelmiin, joita käytetään arvioidessa riskiä sairastua syöpään. Tapaus-verrokkitutkimusasetelma on yksi epidemiologiassa eniten käytetyistä menetelmistä, joita käytetään riskin arvioimisessa. Tapaus-kohorttitutkimusasetelma on yksi tapaus-verrokkitutkimusasetelman versio. Työssä on tarkasteltu asetelmia tutkimuksen suunnittelun, aineistojen keräämisen ja analysoimisen näkökulmista. Tutkielma liittyy Suomen Syöpärekisterin ja NBSBCCC:n (Nordic Biological Specimen Banks working group on Cancer Causes and Control) yhteisiin projekteihin, joissa arvioidaan syöpäriskiä veripankkiaineistoja hyödyntäen. Näissä projekteissa on herännyt kysymys, voidaanko toisia tutkimuksia varten aiemmin kerätyistä tapaus-verrokkiaineistoista tehdä vertailukohortti tapaus-kohorttitutkimukselle ja millä edellytyksin se voitaisiin tehdä? Kysymys on tärkeä, sillä jos aiemmin kerätyt aineistot muodostavat luotettavan vertailukohortin, voidaan biologisia näytteitä käyttävissä hankkeissa säästää kustannuksissa. Menetelmiä sovellettiin kahteen biologiseen aineistoon. Nämä aineistot liittyvät NBSBCCC:n tutkimuksiin, joissa on tutkittu papilloomaviruksen ja eri syöpien välistä yhteyttä. Tämän työn toisessa aineistossa on tutkittu pään ja kaulan alueen syöpiä ja toisessa peräaukon ja sitä ympäröivän ihon syöpiä. Papilloomavirusta kantavilla yksilöillä havaittiin olevan tilastollisesti merkitsevästi suurempi riski sairastua kyseisiin syöpiin. Tulokset olivat samansuuntaisia riippumatta analysointimenetelmästä. Tutkielmassa on pohdittu ehtoja, jotka mahdollistavat tapaus-verrokkiaineistojen käyttämisen uudelleen tapaus-kohorttitutkimuksessa. Nämä ehdot koskevat sekä aineistojen keräämistä että aineistojen analysoimista. Tuloksena on, että aiemmin kerätyt tapaus-verrokkiaineistot voivat muodostaa tapaus-kohorttiaineistolle vertailuryhmän, jos vaadittavat ehdot otetaan huomioon tutkimuksessa. Tärkeimmät lähteet: Barlow, W. E. (1994): Robust Variance Estimation for the Case-Cohort Designs. Biometrics 50(4): 1064-72. Barlow, W. E. – Ichikawa, L. – Rosner, D. – Izumi, S. (1999): Analysis of Case-Cohort Designs. Journal of Clinical Epidemiology 52(12): 1165-72. Gail, M. H. – Benichou, J. (toim.) (2000): Encyclopedia of epidemiologic methods. John Wiley & Sons, New York. Prentice, R. L. (1986): A case-cohort design for epidemiologic cohort studies and disease prevention trials. Biometrika 73(1): 1-11

A Monte Carlo method to estimate the confidence intervals for the concentration index using aggregated population register data.

In this paper, we introduce several statistical methods to evaluate the uncertainty in the concentration index (C) for measuring socioeconomic equality in health and health care using aggregated total population register data. The C is a widely used index when measuring socioeconomic inequality, but previous studies have mainly focused on developing statistical inference for sampled data from population surveys. While data from large population-based or national registers provide complete coverage, registration comprises several sources of error. We simulate confidence intervals for the C with different Monte Carlo approaches, which take into account the nature of the population data. As an empirical example, we have an extensive dataset from the Finnish cause-of-death register on mortality amenable to health care interventions between 1996 and 2008. Amenable mortality has been often used as a tool to capture the effectiveness of health care. Thus, inequality in amenable mortality provides evidence on weaknesses in health care performance between socioeconomic groups. Our study shows using several approaches with different parametric assumptions that previously introduced methods to estimate the uncertainty of the C for sampled data are too conservative for aggregated population register data. Consequently, we recommend that inequality indices based on the register data should be presented together with an approximation of the uncertainty and suggest using a simulation approach we propose. The approach can also be adapted to other measures of equality in health.Peer reviewe

Regional trends in avoidable hospitalisations due to complications among population with diabetes in Finland in 1996-2011 : a register-based cohort study

Objectives: Diabetes requires continuous medical care including prevention of acute complications and risk reduction for long-term complications. Diabetic complications impose a substantial burden on public health and care delivery. We examined trends in regional differences in hospitalisations due to diabetes-related complications among the total diabetes population in Finland. Research design: A longitudinal register-based cohort study 1996-2011 among a total population with diabetes in Finland. Participants: All persons with diabetes identified from several administrative registers in Finland in 1964-2011 and alive on 1 January 1996. Outcome measures: We examined hospitalisations due to diabetes-related short-term and long-term complications, uncomplicated diabetes, myocardial infarction, stroke, lower extremity amputation and end-stage renal disease (ESRD). We calculated annual age-adjusted rates per 10 000 person years and the systematic component of variation. Multilevel models were used for studying time trends in regional variation. Results: There was a steep decline in complication-related hospitalisation rates during the study period. The decline was relatively small in ESRD (30%), whereas rates of hospitalisations for short-term and long-term complications as well as uncomplicated diabetes diminished by about 80%. The overall correlation between hospital district intercepts and slopes in time was -0.72 (p Conclusions: Our study suggests that the prevention of complications among persons with diabetes has improved in Finland between 1996 and 2011. The results further suggest that the prevention of complications has become more uniform throughout the country.Peer reviewe

Excess Mortality in Patients with Severe Mental Disorders in 1996-2010 in Finland

Unselected population-based nationwide studies on the excess mortality of individuals with severe mental disorders are scarce with regard to several important causes of death. Using comprehensive register data, we set out to examine excess mortality and its trends among patients with severe mental disorders compared to the total population. Patients aged 25–74 and hospitalised with severe mental disorders in 1990–2010 in Finland were identified using the national hospital discharge register and linked individually to population register data on mortality and demographics. We studied mortality in the period 1996–2010 among patients with psychotic disorders, psychoactive substance use disorders, and mood disorders by several causes of death. In addition to all-cause mortality, we examined mortality amenable to health care interventions, ischaemic heart disease mortality, disease mortality, and alcohol-related mortality. Patients with severe mental disorders had a clearly higher mortality rate than the total population throughout the study period regardless of cause of death, with the exception of alcohol-related mortality among male patients with psychotic disorders without comorbidity with substance use disorders. The all-cause mortality rate ratio of patients with psychotic disorders compared to the total population was 3.48 (95% confidence interval 2.98–4.06) among men and 3.75 (95% CI 3.08–4.55) among women in the period 2008–10. The corresponding rate ratio of patients with psychoactive substance use disorders was 5.33 (95% CI 4.87–5.82) among men and 7.54 (95% CI 6.30–9.03) among women. Overall, the mortality of the total population and patients with severe mental disorders decreased between 1996 and 2010. However, the mortality rate ratio of patients with psychotic disorders and patients with psychoactive substance use disorders compared to the total population increased in general during the study period. Exceptions were alcohol-related mortality among patients with psychoactive substance use disorders and female patients with psychotic disorders, as well as amenable mortality among male patients with psychotic disorders. The mortality rate ratio of persons with mood disorders compared to the total population decreased. The markedly high mortality amenable to health care intervention among patients with severe mental disorders found in our study suggests indirectly that they may receive poorer quality somatic care. The results highlight the challenges in co-ordinating mental and somatic health services.Public Library of Science open acces

Health information exchange in Finland : Usage of different access types and predictors of paper use

Introduction: Timely, complete and accurate patient data is needed in care decisions along the continuum of care. To access patient data from other organizations, there are three types of regional health information exchange systems (RHIS) in use In Finland. Some regions use multiple RHISs while others do not have a RHIS available. The recently introduced National Patient Data Repository (Kanta) is increasingly used for health information exchange (HIE). Objectives: The purpose of this study was to assess usage of paper, RHISs and Kanta by context in 2017; evolution of paper use over the years; and predictors of paper use in 2017 among Finnish physicians for HIE system development. Methods: Data from national electronic health record (EHR) usage and user experience surveys were taken from 2010 (prior to ePrescription system implementation), 2014 (prior to implementation of Kanta) and 2017 (Kanta was in full use in the public sector and in large private organizations). The web-based surveys were targeted to all physicians engaged in clinical work in Finland. Results: Kanta was the most frequently used means of HIE in 2017. Paper use had reduced significantly from 2010 to 2014. The trend continued in 2017. Still, up to half of the physicians reported using paper daily or weekly in 2017. There were great variations in paper use by healthcare sector, available RHIS type and EHR system used. In multivariable analysis (with all other variables constant), predictors of more frequent use of paper than electronic means for HIE were: private sector or hospital, access to Master Patient Index RHIS (type 1), multiple RHIS (type 4) or no RHIS (type 5), two particular EHR systems, older age, less experience, operative, psychiatric or diagnostic specialties, and male gender. Conclusions: Usability of HIE systems including EHRs as access points to HIE need to be improved to facilitate usage of electronic HIE. Usage ensures more timely and complete patient data for safe, coordinated care. Specialty-specific needs and requirements call for more user participation in HIE design. Especially older professionals need training to better exploit HIS for HIE.Peer reviewe

Trajectory modelling of ambulatory care sensitive conditions in Finland in 1996-2013 : assessing the development of equity in primary health care through clustering of geographic areas - an observational retrospective study

Background Due to stagnating resources and an increase in staff workload, the quality of Finnish primary health care (PHC) is claimed to have deteriorated slowly. With a decentralised PHC organisation and lack of national stewardship, it is likely that municipalities have adopted different coping strategies, predisposing them to geographic disparities. To assess whether these disparities emerge, we analysed health centre area trajectories in hospitalisations due to ambulatory care sensitive conditions (ACSCs). Methods ACSCs, a proxy for PHC quality, comprises conditions in which hospitalisation could be avoided by timely care. We obtained ACSCs of the total Finnish population aged >= 20 for the years 1996-2013 from the Finnish Hospital Discharge Register, and divided them into subgroups of acute, chronic and vaccine-preventable causes, and calculated annual age-standardised ACSC rates by gender in health centre areas. Using these rates, we conducted trajectory analyses for identifying health centre area clusters using group-based trajectory modelling. Further, we applied area-level factors to describe the distribution of health centre areas on these trajectories. Results Three trajectories - and thus separate clusters of health centre areas - emerged with different levels and trends of ACSC rates. During the study period, chronic ACSC rates decreased (40-63%) within each of the clusters, acute ACSC rates remained stable and vaccine-preventable ACSC rates increased (1-41%). While disparities in rate differences in chronic ACSC rates between trajectories narrowed, in the two other ACSC subgroups they increased. Disparities in standardised rate ratios increased in vaccine-preventable and acute ACSC rates between northern cluster and the two other clusters. Compared to the south-western cluster, 13-16% of health centre areas, in rural northern cluster, had 47-92% higher ACSC rates - but also the highest level of morbidity, most limitations on activities of daily living and highest PHC inpatient ward usage as well as the lowest education levels and private health and dental care usage. Conclusions We identified three differing trajectories of time trends for ACSC rates, suggesting that the quality of care, particularly in northern Finland health centre areas, may have lagged behind the general improvements. This calls for further investments to strengthen rural area PHC.Peer reviewe

Tulppaaneita tulvillaan! Kolmas Euroopan kansanterveyskokous

Tulppaaneita tulvillaan! Kolmas Euroopan kansanterveyskokous – 3rd European Public Health Conference: Integrated Public Health, Amsterda

Employment Status and Personal Income Before and After Onset of a Severe Mental Disorder : A Case-Control Study

Objective: Individuals with severe mental disorders have an impaired ability to work and are likely to receive income transfer payments as their main source of income. However, the magnitude of this phenomenon remains unclear. Using longitudinal population cohort register data, the authors conducted a case-control study to examine the levels of employment and personal income before and after a first hospitalization for a serious mental disorder. Methods: All individuals (N=50,551) who had been hospitalized for schizophrenia, other nonaffective psychosis, or bipolar disorder in Finland between 1988 and 2015 were identified and matched with five randomly selected participants who were the same sex and who had the same birth year and month. Employment status and earnings, income transfer payments, and total income in euros were measured annually from 1988 to 2015. Results: Individuals with serious mental disorders had notably low levels of employment before, and especially after, the diagnosis of a severe mental disorder. Their total income was mostly constituted of transfer payments, and this was especially true for those diagnosed as having schizophrenia. More than half of all individuals with a serious mental disorder did not have any employment earnings after they received the diagnosis. Conclusions: The current study shows how most individuals in Finland depend solely on income transfer payments after an onset of a severe mental disorder.Peer reviewe