BackgroundThe ability to accurately detect differential resource use between persons of different socioeconomic status relies on the accuracy of health-needs adjustment measures. This study tests different approaches to morbidity adjustment in explanation of health care utilization inequity.MethodsA representative sample was selected of 10 percent (~270,000) adult enrolees of Clalit Health Services, Israel's largest health care organization. The Johns-Hopkins University Adjusted Clinical Groups® were used to assess each person's overall morbidity burden based on one year's (2009) diagnostic information. The odds of above average health care resource use (primary care visits, specialty visits, diagnostic tests, or hospitalizations) were tested using multivariate logistic regression models, separately adjusting for levels of health-need using data on age and gender, comorbidity (using the Charlson Comorbidity Index), or morbidity burden (using the Adjusted Clinical Groups). Model fit was assessed using tests of the Area Under the Receiver Operating Characteristics Curve and the Akaike Information Criteria.ResultsLow socioeconomic status was associated with higher morbidity burden (1.5-fold difference). Adjusting for health needs using age and gender or the Charlson index, persons of low socioeconomic status had greater odds of above average resource use for all types of services examined (primary care and specialist visits, diagnostic tests, or hospitalizations). In contrast, after adjustment for overall morbidity burden (using Adjusted Clinical Groups), low socioeconomic status was no longer associated with greater odds of specialty care or diagnostic tests (OR: 0.95, CI: 0.94-0.99; and OR: 0.91, CI: 0.86-0.96, for specialty visits and diagnostic respectively). Tests of model fit showed that adjustment using the comprehensive morbidity burden measure provided a better fit than age and gender or the Charlson Index.ConclusionsIdentification of socioeconomic differences in health care utilization is an important step in disparity reduction efforts. Adjustment for health-needs using a comprehensive morbidity burden diagnoses-based measure, this study showed relative underutilization in use of specialist and diagnostic services, and thus allowed for identification of inequity in health resources use, which could not be detected with less comprehensive forms of health-needs adjustments.
BackgroundStrong primary health care (PHC) is the cornerstone for universal health coverage and a country’s health emergency response. PHC includes public health and first-contact primary care (PC). Internationally, the spread of COVID-19 and mortality rates vary widely. The authors hypothesised that countries perceived to have strong PHC have lower COVID-19 mortality rates.AimTo compare perceptions of PC experts on PC system strength, pandemic preparedness, and response with COVID-19 mortality rates in countries globally.Design & settingA convenience sample of international PHC experts (clinicians, researchers, and policymakers) completed an online survey (in English or Spanish) on country-level PC attributes and pandemic responses.MethodAnalyses of perceived PC strength, pandemic plan use, border controls, movement restriction, and testing against COVID-19 mortality were undertaken for 38 countries with ≥5 responses.ResultsIn total, 1035 responses were received from 111 countries, with 1 to 163 responders per country. The 38 countries with ≥5 responses were included in the analyses. All world regions and economic tiers were represented. No correlation was found between PC strength and mortality. Country-level mortality negatively correlated with perceived stringent border control, movement restriction, and testing regimes.ConclusionCountries perceived by expert participants as having a prepared pandemic plan and a strong PC system did not necessarily experience lower COVID-19 mortality rates. What appears to make a difference to containment is if and when the plan is implemented, and how PHC is mobilised to respond. Many factors contribute to spread and outcomes. Important responses are first to limit COVID-19 entry across borders, then to mobilise PHC, integrating the public health and PC sectors to mitigate spread and reduce burden on hospitals through hygiene, physical distancing, testing, triaging, and contract-tracing measures.
Primary health care (PHC) includes both primary care (PC) and essential public health (PH) functions. While much is written about the need to coordinate these two aspects, successful integration remains elusive in many countries. Furthermore, the current global pandemic has highlighted many gaps in a well-integrated PHC approach. Four key actions have been recognized as important for effective integration. A survey of PC stakeholders (clinicians, researchers, and policy-makers) from 111 countries revealed many of the challenges encountered when facing the pandemic without a coordinated effort between PC and PH functions. Participants’ responses to open-ended questions underscored how each of the key actions could have been strengthened in their country and are potential factors to why a strong PC system may not have contributed to reduced mortality. By integrating PC and PH greater capacity to respond to emergencies may be possible if the synergies gained by harmonizing the two are realized.
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