Inequalities In Hospitalization Research Articles

Socioeconomic inequalities in COVID-19 - An analysis of health insurance data

Abstract Background Evidence on socioeconomic inequalities in COVID-19 outcomes largely rests on ecological studies. Only few studies investigated inequalities in different COVID-19 outcomes prospectively on an individual level. We therefore conducted an analysis of German health insurance data to assess socioeconomic inequalities in COVID-19 incidence and hospitalizations within a cohort of insured individuals. Methods We used data of 3.17 million working-aged individuals (18 to 67 years) from various statutory health insurances in Germany. Educational level and occupational position were used as measures of socioeconomic position (SEP). We calculated directly age-standardized incidence rates per 1000 person-weeks (IR) and incidence rate ratios (IRR) among the sample population for COVID-19 incidence and COVID-19 hospitalizations for each exposure during the first four pandemic waves (01.01.2020-31.12.2021). Results Age-standardized IR and IRR of COVID-19 incidence and hospitalizations showed social gradients with higher rates in socioeconomically more disadvantaged groups. Incidence risk was higher among those in a low occupational position (IRR low vs. high: 1.29, 95% CI 1.27-1.31) and with a low level of education (IRR low vs. high: 1.36, 95% CI 1.34-1.38). Inequalities in COVID-19 hospitalizations were more pronounced with an IRR for low vs. high occupational position of 2.29 (95% CI 2.10-2.50) and an IRR for low vs. high level of education of 1.86 (95% CI 1.72-2.03). Conclusions We found socioeconomic inequalities in COVID-19 by education and occupational position, with inequalities in hospitalizations being more pronounced than those in incidence risk. These results show a high potential of prevention to improve population health and health equity in pandemics with novel respiratory pathogens. Further research on the underlying mechanisms of these inequalities in COVID-19 is needed. Key messages • Socioeconomically more disadvantaged individuals have a higher risk of COVID-19 and a severe disease progression. • These inequalities should be addressed in future pandemic preparedness planning in order to minimize the unequal health impacts of pandemics with new emerging diseases.

Area-Level Socioeconomic Inequalities in Intracranial Injury-Related Hospitalization in Korea: A Retrospective Analysis of Data From Korea National Hospital Discharge Survey 2008-2015.

Although inequality in traumatic brain injury (TBI) by individual socioeconomic status (SES) exists, interventions to modify individual SES are difficult. However, as interventions for area-based SES can affect the individual SES, monitoring or public health intervention can be planned. We analyzed the effect of area-based SES on hospitalization for TBI and revealed yearly inequality trends to provide a basis for health intervention. We included patients who were hospitalized due to intracranial injuries (ICIs) between 2008 and 2015 as a measure of severe TBI with data provided by the Korea National Hospital Discharge Survey. Area-based SES was synthesized using the 2010 census data. We assessed inequalities in ICI-related hospitalization rates using the relative index of inequality and the slope index of inequality for the periods 2008-2009, 2010-2011, 2012-2013, and 2014-2015. We analyzed the trends of these indices for the observation period by age and sex. The overall relative indices of inequality for each 2-year period were 1.82 (95% confidence interval, 1.5-2.3), 1.97 (1.6-2.5), 2.01 (1.6-2.5), and 2.01 (1.6-2.5), respectively. The overall slope indices of inequality in each period were 38.74 (23.5-54.0), 36.75 (21.7-51.8), 35.65 (20.7-50.6), and 43.11 (27.6-58.6), respectively. The relative indices of inequality showed a linear trend for men (P = 0.006), which was most evident in the ≥ 65-year age group. Inequality in hospitalization for ICIs by area-based SES tended to increase during the observation period. Practical preventive interventions and input in healthcare resources for populations with low area-based SES are likely needed.

Which Curve Are We Flattening? The Disproportionate Impact of COVID-19 Among Economically Marginalized Communities in Ontario, Canada, Was Unchanged From Wild-Type to Omicron.

Person-level surveillance (N = 14 million) and neighborhood-level income data were used to explore magnitude of inequalities in COVID-19 hospitalizations and deaths over 5 waves in Ontario, Canada. Despite attempts at equity-informed policies alongside fluctuating levels of public health measures, the magnitude of inequalities in hospitalizations and deaths remained unchanged across waves.

Inequalities in hospitalizations for ambulatory care sensitive conditions in New York City before and after the affordable care act

AbstractThe Patient Protection and Affordable Care Act (ACA) was signed into law by U.S. President Obama in 2010 and fully implemented in 2014. The ACA expanded health insurance by expanding the Medicaid program, creating health insurance exchanges (now called “marketplaces”) in which people with incomes between 139% and 400% of the federal poverty level, could purchase subsidized insurance coverage, and by regulating health insurance to eliminate practices such as denying coverage to people with pre‐existing conditions, or basing premiums on health status. We investigate the effects of the ACA's implementation on access to ambulatory health services in New York City by comparing rates of hospitalizations for ambulatory care‐sensitive conditions (ACSC) before and after the full implementation of the law. Although the ACA was associated with a significant decrease in the rate of ACSC in NYC, we find that there continue to be systemic inequalities by gender, race, ethnicity, income, and insurance status. We argue that the broader social and economic inequalities at the national and state levels, including tax and spending policies that have led to increased income and wealth inequalities, help explain why we see persistent inequalities in hospitalizations for ACSC.

Understanding the COVID-19 Pandemic in Nursing Homes (Aragón, Spain): Sociodemographic and Clinical Factors Associated With Hospitalization and Mortality.

Old people residing in nursing homes have been a vulnerable group to the coronavirus disease 2019 (COVID-19) pandemic, with high rates of infection and death. Our objective was to describe the profile of institutionalized patients with a confirmed COVID-19 infection and the socioeconomic and morbidity factors associated with hospitalization and death. We conducted a retrospective cohort study including data from subjects aged 65 years or older residing in a nursing home with a confirmed COVID-19 infection from March 2020 to March 2021 (4,632 individuals) in Aragón (Spain). We analyzed their sociodemographic and clinical profiles and factors related to hospitalization and mortality at 7, 30, and 90 days of COVID-19 diagnosis using logistic regression analyses. We found that the risk of hospitalization and mortality varied according to sociodemographic and morbidity profile. There were inequalities in hospitalization by socioeconomic status and gender. Patients with low contributory pensions and women had a lower risk of hospitalization. Diabetes mellitus, heart failure, and chronic kidney disease were associated with a higher risk of hospitalization. On the contrary, people with dementia showed the highest risk of mortality with no hospitalization. Patient-specific factors must be considered to develop equitable and effective measures in nursing homes to be prepared for future health threats.

Inequality in hospitalization due to non-communicable diseases in Sweden: Age-cohort analysis of the Uppsala Birth Cohort Multigenerational Study.

We aimed to investigate cohort differences in age trajectories of hospitalization due to non-communicable conditions, and if these varied by paternal socioeconomic position. We used the Uppsala Birth Cohort Multigenerational Study—including virtually complete information on medical diagnoses.Our sample constituted 28,448 individuals (103,262 observations). The outcome was five-year prevalence of hospitalization due to major non-communicable conditions in 1989–2008. The exposures were age (19–91), year-of-birth (1915–1929; 1938–1972), gender (man vs woman), and parental socioeconomic position (low, medium, and high). We used multilevel logit models to examine associations between exposures and the hospitalization outcome.Younger cohorts had a higher prevalence of hospitalization at overlapping ages than those born earlier, with inter-cohort differences emerging from early-adulthood and increasing with age. For instance, at age 40 predicted probability of hospitalization increased across birth-cohorts—from 1.2% (born in 1948-52) to 2.0% (born in 1963-67)—whereas at age 50 it was 2.9% for those born in 1938-42 compared with 4.6% among participants born in 1953-57. Those with medium and low socioeconomic position had 13.0% and 20.0% higher odds of experiencing hospitalization during the observation period, respectively—when age, year-of-birth and gender were accounted for.We found that no progress was made in reducing the socioeconomic inequalities in hospitalization across cohorts born between 1915 and 1972. Hence, more effective policies and interventions are needed to reduce the overall burden of morbidity—particularly among the most vulnerable.

Socioeconomic and citizenship inequalities in hospitalisation of the adult population in Italy.

BackgroundHigher levels of hospital admissions among people with lower socioeconomic level, including immigrants, have been observed in developed countries. In Europe, immigrants present a more frequent use of emergency services compared to the native population. The aim of our study was to evaluate the socioeconomic and citizenship differences in the hospitalisation of the adult population in Italy.MethodsThe study was conducted using the database created by the record linkage between the National Health Interview Survey (2005) with the National Hospital Discharge Database (2005–2014). 79,341 individuals aged 18–64 years were included. The outcomes were acute hospital admissions, urgent admissions and length of stay (1–7 days, > = 8 days).Education level, occupational status, self-perceived economic resources and migratory status were considered as socioeconomic determinants.A multivariate proportional hazards model for recurrent events was used to estimate the risk of total hospital admissions. Logistic models were used to estimate the risk of urgent hospitalisation as well as of length of stay.ResultsLow education level, the lack of employment and negative self-perceived economic resources were conditions associated with the risk of hospitalisation, a longer hospital stay and greater recourse to urgent hospitalisation. Foreigners had a lower risk of hospitalisation (HR = 0.75; 95% CI:0.68–0.83) but a higher risk of urgent hospitalisation (OR = 1.36; 95% CI:1.18–1.55) and more frequent hospitalisations with a length of stay of at least eight days (OR = 1.19; 95% CI:1.02–1.40).ConclusionsTo improve equity in access, effective primary, secondary and tertiary prevention strategies must be strengthened, as should access to appropriate levels of care.

Ethnic and racial inequalities in hospital admissions due to avoidable causes in under-five Brazilian children, 2009-2014

There has been a global increase in hospital admissions for primary care-sensitive conditions (PCSCs) as an indicator of effectiveness in primary health care. This article analyzes ethnic and racial inequalities in cause-related hospitalizations in under-five children in Brazil as a whole and the country's five major geographic regions, with an emphasis on PCSCs and acute respiratory infections (ARIs). Using data from the Hospital Information Systems of the Brazilian Unified National Health System (SIH/SUS), 2009-2014, the authors calculated proportions, rates, and rate ratios for PCSCs, adjusted by sex and age after multiple imputation of missing data on color/race. The principal causes of hospitalization were respiratory tract infections (37.4%) and infectious and parasitic diseases (19.3%), and indigenous children were proportionally the most affected. Crude PCSC rates (per 1,000) were highest in indigenous children (97.3; 95%CI: 95.3-99.2), followed by brown or mixed-raced children (40.0; 95%CI: 39.8-40.1), while the lowest rates were in Asiandescendant children (14.8; 95%CI: 14.1-15.5). The highest adjusted rate ratios for PCSCs were seen among indigenous children compared to white children - 5.7 (95%CI: 3.9-8.4) for Brazil as a whole, reaching 5.9 (95%CI: 5.0-7.1) and 18.5 (95%CI: 16.5-20.7) in the North and Central, respectively, compared to white children. ARIs remained as important causes of pediatric hospitalizations in Brazil. Alarming ethnic and racial inequalities were observed in PCSCs, with indigenous children at a disadvantage. Improvements are needed in living conditions, sanitation, and subsistence, as well as guaranteed timely access to high-quality primary health care in the more vulnerable population groups, especially the indigenous peoples of the North and Central, in order to mitigate the health inequalities and meet the guidelines of the SUS and the Brazilian Constitution.

Health inequalities in hospitalisation and mortality in patients diagnosed with heart failure in a universal healthcare coverage system

BackgroundInformation regarding the effect of social determinants of health on heart failure (HF) community-dwelling patients is scarce. We aimed to analyse the presence of socioeconomic inequalities, and their impact on...

Ethnic inequalities in acute myocardial infarction hospitalization rates among young and middle-aged adults in Northern Italy: high risk for South Asians.

The knowledge of ethnic-specific health needs is now essential to design effective health services and population-based prevention strategies. However, data on migrant populations living in Southern Europe are limited. The study is designed to investigate ethnic inequalities in hospitalization for acute myocardial infarction (AMI) in the Veneto region (Italy). Hospital admissions for AMI in Veneto for the whole resident population aged 20-59years during 2008-2013 were studied. Age and gender-specific AMI hospitalization rates for immigrant groups (classified by country of origin according to the United Nations geoscheme) and Italians were calculated. The indirect standardization method was used to estimate standardized hospitalization ratios (SHR) for each immigrant group, with rates of Italian residents as a reference. Overall, 8200 AMI events were retrieved, 648 among immigrants. The highest risk of AMI is seen in South Asians males (SHR 4.2, 95% CI 3.6-4.9) and females (SHR 2.5, 95% CI 1.4-4.5). AMI rates in South Asian males sharply increase in the 30-39years age class. Other immigrant subgroups (Eastern Europe, North Africa, Sub-Saharan Africa, other Asian countries, Central-South America, high-income countries) displayed age- and gender-adjusted hospitalization rates similar to the native population. Present findings stress the urgent need for implementation of ethnic-specific health policies in Italy. The awareness about the high cardiovascular risk in subjects from South Asia must be increased among general practitioners and immigrant communities.

Four Decades of Educational Inequalities in Hospitalization and Mortality among Older Swedes.

BackgroundThe inverse association between education and mortality has grown stronger the last decades in many countries. During the same period, gains in life expectancy have been concentrated to older ages; still, old-age mortality is seldom the focus of attention when analyzing trends in the education-mortality gradient. It is further unknown if increased educational inequalities in mortality are preceded by increased inequalities in morbidity of which hospitalization may be a proxy.MethodsUsing administrative population registers from 1971 and onwards, education-specific annual changes in the risk of death and hospital admission were estimated with complimentary log-log models. These risk changes were supplemented by estimations of the ages at which 25, 50, and 75% of the population had been hospitalized or died (after age 60).ResultsThe mortality decline among older people increasingly benefitted the well-educated over the less well-educated. This inequality increase was larger for the younger old, and among men. Educational inequalities in the age of a first hospital admission generally followed the development of growing gaps, but at a slower pace than mortality and inequalities did not increase among the oldest individuals.ConclusionsEducation continues to be a significant predictor of health and longevity into old age. That the increase in educational inequalities is greater for mortality than for hospital admissions (our proxy of overall morbidity) may reflect that well-educated individuals gradually have obtained more possibilities or resources to survive a disease than less well-educated individuals have the last four decades.

Has the Rajiv Aarogyasri Community Health Insurance Scheme of Andhra Pradesh Addressed the Educational Divide in Accessing Health Care?

BackgroundEquity of access to healthcare remains a major challenge with families continuing to face financial and non-financial barriers to services. Lack of education has been shown to be a key risk factor for 'catastrophic' health expenditure (CHE), in many countries including India. Consequently, ways to address the education divide need to be explored. We aimed to assess whether the innovative state-funded Rajiv Aarogyasri Community Health Insurance Scheme of Andhra Pradesh state launched in 2007, has achieved equity of access to hospital inpatient care among households with varying levels of education.MethodsWe used the National Sample Survey Organization 2004 survey as our baseline and the same survey design to collect post-intervention data from 8623 households in the state in 2012. Two outcomes, hospitalisation and CHE for inpatient care, were estimated using education as a measure of socio-economic status and transforming levels of education into ridit scores. We derived relative indices of inequality by regressing the outcome measures on education, transformed as a ridit score, using logistic regression models with appropriate weights and accounting for the complex survey design.FindingsBetween 2004 and 2012, there was a 39% reduction in the likelihood of the most educated person being hospitalised compared to the least educated, with reductions observed in all households as well as those that had used the Aarogyasri. For CHE the inequality disappeared in 2012 in both groups. Sub-group analyses by economic status, social groups and rural-urban residence showed a decrease in relative indices of inequality in most groups. Nevertheless, inequalities in hospitalisation and CHE persisted across most groups.ConclusionDuring the time of the Aarogyasri scheme implementation inequalities in access to hospital care were substantially reduced but not eliminated across the education divide. Universal access to education and schemes such as Aarogyasri have the synergistic potential to achieve equity of access to healthcare.

Portrait of socio‐economic inequality in childhood morbidity and mortality over time, Québec, 1990–2005

To determine the age and cause groups contributing to absolute and relative socio-economic inequalities in paediatric mortality, hospitalisation and tumour incidence over time. Deaths (n= 9559), hospitalisations (n= 834,932) and incident tumours (n= 4555) were obtained for five age groupings (<1, 1-4, 5-9, 10-14, 15-19 years) and four periods (1990-1993, 1994-1997, 1998-2001, 2002-2005) for Québec, Canada. Age- and cause-specific morbidity and mortality rates for males and females were calculated across socio-economic status decile based on a composite deprivation score for 89 urban communities. Absolute and relative measures of inequality were computed for each age and cause. Mortality and morbidity rates tended to decrease over time, as did absolute and relative socio-economic inequalities for most (but not all) causes and age groups, although precision was low. Socio-economic inequalities persisted in the last period and were greater on the absolute scale for mortality and hospitalisation in early childhood, and on the relative scale for mortality in adolescents. Four causes (respiratory, digestive, infectious, genito-urinary diseases) contributed to the majority of absolute inequality in hospitalisation (males 85%, females 98%). Inequalities were not pronounced for cause-specific mortality and not apparent for tumour incidence. Socio-economic inequalities in Québec tended to narrow for most but not all outcomes. Absolute socio-economic inequalities persisted for children <10 years, and several causes were responsible for the majority of inequality in hospitalisation. Public health policies and prevention programs aiming to reduce socio-economic inequalities in paediatric health should account for trends that differ across age and cause of disease.

Magnitude and shape of income inequalities in hospitalization for all causes in Italy

Background : Few of the studies that have evaluated the impact of income on health and health services utilisation have been conducted in southern Europe and have focused on the shape of the relationship. This study aimed at evaluating the hospitalisation gradient by small area income and to analyse its shape, with data from four large Italian cities. Methods : Census tract (median 260 residents) median per capita income was computed through record linkage between 1998 national tax and local population registries in the cities of Rome, Turin, Milan and Bologna (total population of approximately 5.5 million). Census tract median income was assigned to general acute hospital discharges in the period 1997-2000 among residents in the cities, on the basis of the patient’s residence. Within each stratum defined by gender and age group (0-64, 65+), standardised hospital discharge rates were computed for quantiles of census tract median income. A segmented non-linear model was fitted to discharge rates across percentiles, as function of median value of census tract median income in each percentile. Results : This study showed an inverse gradient in hospitalizations with increasing small area income. A less marked decrease in the standardised discharge rates was shown above approximately €12,000 census tract median per capita income, for both males and females and for the two age-groups considered. Conclusions : Small area income seems to have a strong association with hospitalisation, acting through a differential occurrence of diseases and/or access to health services. Among the wealthiest persons, the results suggest the diminishing return of health and/or appropriateness of health care with increasing income.

Internações por Diabetes Mellitus como diagnóstico principal na Rede Pública do Brasil, 1999-2001

OBJETIVO: Descrever no âmbito nacional e por faixa etária, sexo e região as 327.800 hospitalizações por diabetes mellitus (DM) da rede pública do Brasil, entre 1999-2001. MÉTODOS: Foram utilizados dados do Sistema de Informação Hospitalar do Sistema Único de Saúde (SIH/SUS) referentes ao DM (diagnóstico principal CID-10 E10-E14 combinado com procedimento realizado) e indicadores anuais de hospitalizações/10(4)hab. e óbitos hospitalares/10(6)hab. (ajustados pelo método direto por idade), letalidade, médias de permanência e gastos por internação e por 10(4)hab. em US$, e regressão logística múltipla para desfecho óbito. RESULTADOS: Houve mais hospitalizações anuais do sexo feminino (7,5/10(4)hab. [intervalo de confiança de 95%: 7,4-7,6] vs. masculino (5,2/10(4)hab. [5,2-5,3]), mais óbitos hospitalares anuais de mulheres (38,1/10(6)hab. [36,8-39,3] vs. 30,7 [29,5-32,0]), porém maior letalidade no sexo masculino (5,9 vs. 5,0%) em todas as regiões. Observou-se incremento das hospitalizações com a idade, mais acentuado para mulheres. Não houve diferença na permanência das internações com óbito (6,5 dias [6,3-6,6]) ou sem (6,4 [6,3-6,6]), apesar do gasto por internação superior (US$ 275,27 [268,37-282,16] vs. 143,45 [136,56-150,35]). O gasto anual/10(4)hab. equivaleu a US$ 969,09. A razão de chances de óbito hospitalar aumentou com a idade, foi maior para homens (1,21 [1,17-1,24]) e 2 vezes maior para habitantes das regiões Nordeste e Sudeste comparados aos da região Sul. Os gastos anuais/10(4)hab. foram 50-100% maiores nas regiões mais desenvolvidas. CONCLUSÕES: O volume e a desigualdade nos gastos enfatizam a necessidade de cobertura mais adequada da população, evitando as hospitalizações e suas complicações.

Assistência hospitalar como indicador da desigualdade social

To test a model for the study of inequalities in hospitalizations in the city of Ribeirâo Preto (SP), understanding them to be due both to the social position of inpatients and also to health care policies in Brazil. Using a hospital information system in existence for more than 25 years in the city of Ribeirâo Preto-SP, 56.293 hospitalizations of municipal inhabitants occurring in some of the 12 general hospitals in 1993, were studied. Using the Brazilian occupancy classification for mortality, these inpatients were grouped on 6 occupational levels, as in the British classification: professional, intermediate, qualified non manual, qualified manual, partially qualified and unqualified. Two-thirds of the inpatients had no place in the i.e. did not belong to the economically active population--and consisted of housewives, pensioners, children and students--and one third had some economic activity and thus belonged to the economically the active population. A close association was found between social strata and the classification of the hospital financing system into private, private group clinic and public health system patients. There were differences in hospital parameters as well as in morbidity patterns between these groups. The inequalities relating to average age, average age of hospital deaths, mean lengths of stay, hospital mortality, re-internment and frequency of diseases are discussed. This model allows the social position of the inpatient to be estimated using the hospital financing system, including also those patients with no economic activity, which covers the majority of the population. Social mechanisms created to compensate for inequalities in the welfare state do not cancel out the social differences.