Socioeconomic inequality of diabetes patients’ health care utilization in Denmark

Abstract

Understanding socioeconomic inequalities in health care is critical for achieving health equity. The aim of this paper is threefold: 1) to quantify inequality in diabetes health care service utilization; 2) to understand determinants of these inequalities in relation to socio-demographic and clinical morbidity factors; and 3) to compare the empirical outcome of using income level and educational level as proxies for Socio Economic Status (SES).Data on the entire Danish population of diabetes patients in 2011 (N = 318,729) were applied. Patients’ unique personal identification number enabled individual patient data from several national registers to be linked. A concentration index approach with decomposition into contributing factors was applied. Differences in diabetes patients’ health care utilization patterns suggest that use of services differ among patients of lower and higher SES, despite the Danish universal health care system. Especially, out-patient services, rehabilitation and specialists in primary care show different utilization patterns according to SES. Comparison of the empirical outcome from using educational level and income level as proxy for patients’ SES indicate important differences in inequality estimates. While income, alike other measures of labor market attachment, to a certain extent is explained by morbidity and thus endogenous, education is more decisive for patients’ ability to take advantage of the more specialized services provided in a universal health care system.

Is the Rule of Halves framework relevant for diabetes care in Copenhagen today? A register-based cross-sectional study

“…With regard to ethnic differences, we found that men and migrants form the Middle East and Africa were less likely to receive foot examinations or have well-regulated HbA1c, and that some migrant groups scored high on microvascular complications, but the ethnic differences were often not large enough to be verified. The DVDD study does not include data on patient’s socioeconomic position, but recent studies from Denmark have shown clear socioeconomic inequalities in diabetes care utilisation, 24 regulation, 25 complications and survival. 12 …”

Socio-demographic determinants and effect of structured personal diabetes care: a 19-year follow-up of the randomized controlled study diabetes Care in General Practice (DCGP)

“…Thus the results do not confirm results from studies of the general population showing that the number of consultations at the GP increases with decreasing socio-economic status [ 15 , 32 ]. The fact that socio-economic differences in mortality and morbidity persist, despite formally equal access to the public health care system, could be due to different use of specialist care as suggested by others [ 17 , 20 ], but this does not seem to be the case for the intervention in our study.…”

“…The presented benefit of structured personal care on long-term endpoints, also for patients with low level of education and patients on welfare benefits, cannot be ascribed to single elements of complex interventions. Patients with low level of education and income are frequently reported to be inadequately controlled with hyperglycaemia, hypertension, dyslipidaemia and unhealthy lifestyle [ 14 , 15 ], and some studies also suggest socio-demographic differences in prescription rates [ 16 , 20 ]. Our results are in line with earlier studies, concerning socio-demographic differences of intensive multifactorial interventions, which have been shown not to worsen or introduce social inequity in the control of T2DM [ 13 , 21 , 33 ].…”

“…Though SES and place of living influence care and prognosis of T2DM [ 8 , 10 , 11 , 20 ], there is only limited evidence as to whether the effectiveness of diabetes interventions differs with regard to SES and residence. Recent reports suggest that interventions with intensive diabetes care diminish the socio-economic differences in intermediate outcomes [ 13 , 21 ], but we do not know whether this effect also is seen on long-term outcomes.…”

Disentangling the influence of living place and socioeconomic position on health services use among diabetes patients: A population-based study

“…Many works support that socioeconomic-related differences exist in diabetes control and care, despite the presence of universal health coverage which may be seen as a facility that ensure the affordability of care. Patients with a lower socioeconomic position (SEP) had a lower rate of control of diabetes [ 1 – 3 ], lower access to preventive care as suggested by higher complication rates and morbidity [ 1 , 4 – 8 ], higher general practitioner attendance rates but lower rates of hospital and specialised care attendance [ 1 , 3 , 4 , 9 – 11 ]. These studies did not account for nor investigate the role of the geographical context despite evidences supporting the influence of the living place on patients’ use of health services, in different healthcare systems.…”