Explaining regional variation in elective hip and knee arthroplasties in Finland 2010 - 2017-a register-based cohort study.

BACKGROUND: A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need. METHODS: We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models - individuals and hospital regions - were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 - 2013 and 2014 - 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios. RESULTS: We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 - 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 - 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 - 2013, but only 5% in 2014 - 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially. CONCLUSIONS: Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.

Cumulative social disadvantage and hospitalisations due to ambulatory care-sensitive conditions in Finland in 2011─2013: a register study.

OBJECTIVES: To study the interplay between several indicators of social disadvantage and hospitalisations due to ambulatory care-sensitive conditions (ACSC) in 2011─2013. To evaluate whether the accumulation of preceding social disadvantage in one point of time or prolongation of social disadvantage had an effect on hospitalisations due to ACSCs. Four common indicators of disadvantage are examined: living alone, low level of education, poverty and unemployment. DESIGN: A population-based register study. SETTING: Nationwide individual-level register data on hospitalisations due to ACSCs for the years 2011-2013 and preceding data on social and socioeconomic factors for the years 2006─2010. PARTICIPANTS: Finnish residents aged 45 or older on 1 January 2011. OUTCOME MEASURE: Hospitalisations due to ACSCs in 2011-2013. The effect of accumulation of preceding disadvantage in one point of time and its prolongation on ACSCs was studied using modified Poisson regression. RESULTS: People with preceding cumulative social disadvantage were more likely to be hospitalised due to ACSCs. The most hazardous combination was simultaneously living alone, low level of education and poverty among the middle-aged individuals (aged 45-64 years) and the elderly (over 64 years). Risk ratio (RR) of being hospitalised due to ACSC was 3.16 (95% CI 3.03-3.29) among middle-aged men and 3.54 (3.36-3.73) among middle-aged women compared with individuals without any of these risk factors when controlling for age and residential area. For the elderly, the RR was 1.61 (1.57-1.66) among men and 1.69 (1.64-1.74) among women. CONCLUSIONS: To improve social equity in healthcare, it is important to recognise not only patients with cumulative disadvantage but also-as this study shows-patients with particular combinations of disadvantage who may be more susceptible. The identification of these vulnerable patient groups is also necessary to reduce the use of more expensive treatment in specialised healthcare.

Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study.

BACKGROUND: The number of online services in health care is increasing rapidly in developed countries. Users are expected to take a more skilled and active role in taking care of their health and prevention of ill health. This induces risks that users (especially those who need the services the most) will drop out of digital services, resulting in a digital divide or exclusion. To ensure wide and equal use of online services, all users must experience them as beneficial. OBJECTIVE: This study aimed to examine associations of (1) demographics (age, gender, and degree of urbanization), (2) self-rated health, (3) socioeconomic position (education, experienced financial hardship, labor market position, and living alone), (4) social participation (voting, satisfaction with relationships, and keeping in touch with friends and family members), and (5) access, skills, and extent of use of information and communication technologies (ICT) with perceived benefits of online health care and social welfare services. Associations were examined separately for perceived health, economic, and collaboration benefits. METHODS: We used a large random sample representative of the Finnish population including 4495 (56.77% women) respondents aged between 20 and 97 years. Analyses of covariance were used to examine the associations of independent variables with perceived benefits. RESULTS: Access to online services, ICT skills, and extent of use were associated with all examined benefits of online services. ICT skills seemed to be the most important factor. Poor self-rated health was also consistently associated with lower levels of perceived benefits. Similarly, those who were keeping in touch with their friends and relatives at least once a week perceived online services more often beneficial in all the examined dimensions. Those who had experienced financial hardship perceived fewer health and economic benefits than others. Those who were satisfied with their relationships reported higher levels of health and collaboration benefits compared with their counterparts. Also age, education, and degree of urbanization had some statistically significant associations with benefits but they seemed to be at least partly explained by differences in access, skills, and extent of use of online services. CONCLUSIONS: According to our results, providing health care services online has the potential to reinforce existing social and health inequalities. Our findings suggest that access to online services, skills to use them, and extent of use play crucial roles in perceiving them as beneficial. Moreover, there is a risk of digital exclusion among those who are socioeconomically disadvantaged, in poor health, or socially isolated. In times when health and social services are increasingly offered online, this digital divide may predispose people with high needs for services to exclusion from them.

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.

Trends of socioeconomic equality in mortality amenable to healthcare and health policy in 1992-2013 in Finland: a population-based register study.

OBJECTIVE: To study trends in socioeconomic equality in mortality amenable to healthcare and health policy interventions. DESIGN: A population-based register study. SETTING: Nationwide data on mortality from the Causes of Death statistics for the years 1992-2013. PARTICIPANTS: All deaths of Finnish inhabitants aged 25-74. OUTCOME MEASURES: Yearly age-standardised rates of mortality amenable to healthcare interventions, alcohol-related mortality, ischaemic heart disease mortality and mortality due to all the other causes by income. Concentration index (C) was used to evaluate the magnitude and changes in income group differences. RESULTS: Significant socioeconomic inequalities favouring the better-off were observed in each mortality category among younger (25-64) and older (65-74) age groups. Inequality was highest in alcohol-related mortality, C was -0.58 (95% CI -0.62 to -0.54) among younger men in 2008 and -0.62 (-0.72 to -0.53) among younger women in 2013. Socioeconomic inequality increased significantly during the study period except for alcohol-related mortality among older women. CONCLUSIONS: The increase in socioeconomic inequality in mortality amenable to healthcare and health policy interventions between 1992 and 2013 suggests that either the means or the implementation of the health policies have been inadequate.

Trends of relative and absolute socioeconomic equity in access to coronary revascularisations in 1995-2010 in Finland: a register study.

BACKGROUND: Resources for coronary revascularisations have increased substantially since the early 1990s in Finland. At the same time, ischaemic heart disease (IHD) mortality has decreased markedly. This study aims to examine how these changes have influenced trends in absolute and relative differences between socioeconomic groups in revascularisations and age group differences in them using IHD mortality as a proxy for need. METHODS: Hospital Discharge Register data on revascularisations among Finns aged 45-84 in 1995-2010 were individually linked to population registers to obtain socio-demographic data. We measured absolute and relative income group differences in revascularisation and IHD mortality with slope index of inequality (SII) and concentration index (C), and relative equity taking need for care into account with horizontal inequity index (HII). RESULTS: The supply of procedures doubled during the years. Socioeconomic distribution of revascularisations was in absolute and relative terms equal in 1995 (Men: SII = -12, C = -0.00; Women, SII = -30, C = -0.03), but differences favouring low-income groups emerged by 2010 (M: SII = -340, C = -0.08; W: SII = -195, C = -0.14). IHD mortality decreased markedly, but absolute and relative differences favouring the better-off existed throughout study years. Absolute differences decreased somewhat (M: SII = -760 in 1995, SII = -681 in 2010; W: SII = -318 in 1995, SII = -211 in 2010), but relative differences increased significantly (M: C = -0.14 in 1995, C = -0.26 in 2010; W: C = -0.15 in 1995, C = -0.25 in 2010). HII was greater than zero in each year indicating inequity favouring the better-off. HII increased from 0.15 to 0.18 among men and from 0.10 to 0.12 among women. We found significant and increasing age group differences in HII. CONCLUSIONS: Despite large increase in supply of revascularisations and decrease in IHD mortality, there is still marked socioeconomic inequity in revascularisations in Finland. However, since changes in absolute distributions of both supply and need for coronary care have favoured low-income groups, absolute inequity can be claimed to have decreased although it cannot be quantified numerically.

Comparative observational study of mortality amenable by health policy and care between rural and urban Finland: no excess segregation of mortality in the capital despite its increasing residential differentiation.

BACKGROUND: Large cities are often claimed to display more distinct geographical and socioeconomic health inequalities than other areas due to increasing residential differentiation. Our aim was to assess whether geographical inequalities in mortality within the capital (City of Helsinki) both exceeded that in other types of geographical areas in Finland, and whether those differences were dependent on socioeconomic inequalities. METHODS: We analysed the inequality of distribution separately for overall, ischemic heart disease and alcohol-related mortality, and mortality amenable (AM) to health care interventions in 1992-2008 in three types of geographical areas in Finland: City of Helsinki, other large cities, and small towns and rural areas. Mortality data were acquired as secondary data from the Causes of Death statistics from Statistics Finland. The assessment of changing geographical differences over time, that is geographical inequalities, was performed using Gini coefficients. As some of these differences might arise from socioeconomic factors, we assessed socioeconomic differences with concentration indices in parallel to an analysis of geographical differences. To conclude the analysis, we compared the changes over time of these inequalities between the three geographical areas. RESULTS: While mortality rates mainly decreased, alcohol-related mortality in the lowest income quintile increased. Statistically significant differences over time were found in all mortality groups, varying between geographical areas. Socioeconomic differences existed in all mortality groups and geographical areas. In the study period, geographical differences in mortality remained relatively stable but income differences increased substantially. For instance, the values of concentration indices for AM changed by 54 % in men (p < 0.027) and by 62 % in women (p < 0.016). Only slight differences existed in the time trends of Gini or in the concentration indices between the geographical areas. CONCLUSIONS: No geographical or income-related differences in the distribution of mortality existed between Helsinki and other urban or rural areas of Finland. This suggests that the effect of increasing residential differentiation in the capital may have been mitigated by the policies of positive discrimination and social mixing. One of the main reasons for the increase in health inequalities was growth of alcohol-related mortality, especially among those with the lowest incomes.

National and regional trends in equity within specialised health care in Finland in 2002-2010.

AIMS: Equity is an important goal of health-care systems. Nevertheless, previous research indicates that health-care systems do not deliver health services equitably and that socio-economic differences in both health and health-care use may even be increasing. The aim of this study was to investigate national and regional time trends in equity within specialised health care in Finland. METHODS: The data used in the study were obtained from the Hospital Discharge Register covering all hospital admissions in Finland from 2002 to 2010 for patients having utilised specialised non-psychiatric inpatient care. Income data were individually linked to these register data. Equity was measured in terms of concentration index at hospital district level. RESULTS: Concentration indices across hospital districts and years were negative, suggesting specialised inpatient care to be distributed pro poor. Overall, the concentration indices remained fairly stable during the study period. However, a drop in the indices appeared in all hospital districts between 2005 and 2008, and a reverse development was found after 2008. In internal medicine departments of the hospital districts, the distribution of the indices was more pro poor compared to surgery but the trends within both specialties were similar to those within specialised care in general. CONCLUSIONS: The pro-poor distribution of concentration indices is consistent with morbidity differences the introduction of the waiting time guarantee in 2005, which brought along an increment in resources, as well as the launch of new regulations and financial incentives, probably increased access to specialised health care among low-income patients temporarily.

Has socioeconomic equity increased in somatic specialist care: a register-based cohort study from Finland in 1995-2010.

BACKGROUND: Equal access to health care according to need is an important goal for health policy in Finland. Earlier research in Finland and elsewhere has mainly been cross-sectional, but the results have implied that the goal has not been fully realised in somatic specialist hospital care. This study examines trends in socioeconomic equity in use of somatic specialist hospital care. METHODS: We used register data on somatic specialist hospital admissions among 25-84 year-old persons in Finland in 1995-2010 with individually linked register-based socio-demographic information. We calculated age-standardised admission rates per 100,000 person years by income, examined risk ratios using Poisson regression models and computed concentration indices separately for men and women. Linear trends in the socioeconomic distribution of admissions and surgical procedures were estimated with linear regression models for annual concentration indices. RESULTS: Overall, use of somatic specialist hospital care decreased steadily throughout the study period. A stepwise inverse income pattern was found in hospitalisation risk and in non-surgical admissions: the lower the income group, the higher the risk. The relative admission risk was approximately two times higher in the lowest income group compared to the highest among both genders. Few differences were found in surgical admissions. Income group differences remained stable in hospitalisations and surgical admissions, but increased in non-surgical admissions during the study period. An inverse pattern of increasing operation rates with decreasing income was found in primary hip and knee replacement operations, and in lower limb amputations. A similar pattern emerged during the study period in coronary revascularisations. There were no differences were found in lumbar fusion or lumbar disc operations, prostatectomies or appendectomies. Income group differences in hysterectomies disappeared during the study period. CONCLUSIONS: While the results of the current study suggest that use of somatic specialist care declined in line with improving population health in 1995-2010, the increase of socioeconomic health differentials was only partly reflected in the distribution of somatic specialist hospital care. Further research is needed to evaluate the need to improve use and content of specialised hospital care among the low-income groups in order to improve equity in health care.

Multiple social disadvantage does it have an effect on amenable mortality: a brief report.

INTRODUCTION: Most studies on inequalities in health and health-care focus on single indicators of social position, e.g. income or education. Recent research has suggested that multiple social circumstances need to be analysed simultaneously to disentangle their influence on health. In past decades mortality amenable to health-care, i.e. premature mortality that should not occur given timely and effective health-care, has increasingly been used to study the effect of health-care on health outcomes. This study elaborates the effect of social and regional deprivation and unemployment on the association between income and mortality amenable to health-care in Finland. METHODS: Individual-level data for deaths were gathered by disease category between 1992 and 2008 for the resident Finnish population aged 25 to 59 years. Differences in amenable mortality and changes over time were assessed using individual-level linked register data. We used gender- and age-standardised rates and Poisson regression models to examine the simultaneous effect of these indicators on amenable mortality. RESULTS: Altogether 22,663 persons aged 25-59 years died from causes amenable to health-care during the study period. An inverse pattern was found in amenable mortality for income. The mortality rate in the lowest income quintile was 98 (93-104) per 100,000 in the period 1991-1996 while in the highest group the figure was 40 (38-42) for the same period. Whereas the level of amenable mortality decreased, mortality differences between income groups steepened and amenable mortality increased in the lowest income group towards the end of the study period. Those in poor labour market position or living alone had significantly larger income differences in amenable mortality. Risk of regional deprivation was not associated with amenable mortality. CONCLUSIONS: In order to prevent and treat at an early phase conditions that otherwise may lead to premature and unnecessary deaths more attention should be focused on groups with increased social and economic deprivation risk in municipal health centres with the aim at improving access to primary care. Our results also call for joint action by both health-care and social services, since health services alone cannot deal with the risks posed by accumulating social disadvantage.

The development of differences in hospital costs accross income groups in Finland from 1998 to 2010.

OBJECTIVE: To quantify differences in hospital costs between socioeconomic groups and the development over time. METHODS: Register data on somatic specialised hospital admissions for patients aged between 25 and 84 in Finland in 1998-2010 were used with income data individually linked to them. The cost of an admission was calculated by multiplying the number of a patient's inpatient days by the inpatient day cost of the patient's DRG. We calculated age-standardised admission costs per resident and per user as well as costs per inpatient day and concentration indices separately for men and women. RESULTS: Hospital admission costs reduced with increasing income. The difference between the extreme income quintiles was more than 50% throughout the study period, and this difference widened. However, the cost per inpatient day was more than 20% higher in the highest income group. The differences between income groups were the most prominent in disease categories involving surgery. CONCLUSIONS: The growth between socioeconomic groups in hospital costs is presumably mainly due to increasing differences in morbidity. More attention needs to be paid to prevention of health inequalities and access to and content of primary care among low-income groups in order to decrease the need for hospitalisations.

Amenable mortality by household income and living arrangements: a linked register-based study of Finnish men and women in 2000-2007.

BACKGROUND: Mortality amenable to healthcare interventions has increasingly been used as an indirect indicator of the effect of healthcare on health inequalities. Studies have consistently shown socioeconomic differences in amenable mortality, but evidence on the joint effects of multiple socioeconomic and demographic factors is limited. We examined whether income and living arrangements have an independent effect on amenable mortality taking into account other dimensions of social position. METHODS: The longitudinal and yearly updated individual level data were derived from different administrative registers and obtained from Statistics Finland. The data set includes an 11% random sample of all individuals aged 25-74 years at the end of 1999 and an 80% oversample of deaths in the follow-up period between 2000 and 2007. We used Cox proportional hazard regression with appropriate weights. RESULTS: We found twofold to threefold differences in amenable mortality between the top and bottom income quintiles. These differences were found to be largely attenuated by economic activity and living arrangements. We also found differences in amenable mortality by living arrangements suggesting that those living alone, as well as lone parents and those cohabiting have higher amenable mortality. These differences were largely independent of our indicators of socioeconomic position and economic activity. CONCLUSIONS: While our results give indirect support to the hypothesis that income differences in amenable mortality may be at least partially due to barriers in access to care, the large independent effects of living arrangements on amenable mortality suggest that seeking care may also have an impact.

The contribution of health policy and care to income differences in life expectancy--a register based cohort study.

BACKGROUND: Growing mortality differences between socioeconomic groups have been reported in both Finland and elsewhere. While health behaviours and other lifestyle factors are important in contributing to health differences, some researchers have suggested that some of the mortality differences attributable to lifestyle factors could be preventable by health policy measures and that health care may play a role. It has also been suggested that its role is increasing due to better results in disease prevention, improved diagnostic tools and treatment methods. This study aimed to assess the impact of mortality amenable to health policy and health care on increasing income disparities in life expectancy in 1996-2007 in Finland. METHODS: The study data were based on an 11% random sample of Finnish residents in 1988-2007 obtained from individually linked cause of death and population registries and an oversample of deaths. We examined differences in life expectancy at age 35 (e35) in Finland. We calculated e35 for periods 1996-97 and 2006-07 by income decile and gender. Differences in life expectancies and change in them between the richest and the poorest deciles were decomposed by cause of death group. RESULTS: Overall, the difference in e35 between the extreme income deciles was 11.6 years among men and 4.2 years among women in 2006-07. Together, mortality amenable to health policy and care and ischaemic heart disease mortality contributed up to two thirds to socioeconomic differences. Socioeconomic differences increased from 1996-97 by 3.4 years among men and 1.7 years among women. The main contributor to changes was mortality amenable through health policy measures, mainly alcohol related mortality, but also conditions amenable through health care, ischaemic heart disease among men and other diseases contributed to the increase of the differences. CONCLUSIONS: The results underline the importance of active health policy and health care measures in tackling socioeconomic health inequalities.

Can organizational justice help the retention of general practitioners?

In many countries, public sector has major difficulties in recruiting and retaining physicians to work as general practitioners (GPs). We examined the effects of taking up a public sector GP position and leaving public sector GP work on the changes of job satisfaction, job involvement and turnover intentions. In addition, we examined whether organizational justice in the new position would moderate these associations. This was a four-year prospective questionnaire study including two measurements among 1581 (948 women, 60%) Finnish physicians. A change to work as a public GP was associated with a substantial decrease in job satisfaction and job involvement when new GPs experienced that their primary care organization was unfair. However, high organizational justice was able to buffer against these negative effects. Those who changed to work as public GPs had 2.8 times and those who stayed as public GPs had 1.6 times higher likelihood of having turnover intentions compared to those who worked in other positions. Organizational justice was not able to buffer against this effect. Primary care organizations should pay more attention to their GPs - especially to newcomers - and to the fairness how management behaves towards employees, how processes are determined, and how rewards are distributed.

Socioeconomic differences in mortality amenable to health care among Finnish adults 1992-2003: 12 year follow up using individual level linked population register data.

BACKGROUND: Finland decentralised its universal healthcare system and introduced market reforms in the 1990s. Despite a commitment to equity, previous studies have identified persistent socio-economic inequities in healthcare, with patterns of service use that are more pro-rich than in most other European countries. To examine whether similar socio-economic patterning existed for mortality amenable to intervention in primary or specialist care, we investigated trends in amenable mortality by income group from 1992-2003. METHODS: We analysed trends in all cause, total disease and mortality amenable to health care using individual level data from the National Causes of Death Register for those aged 25 to 74 years in 1992-2003. These data were linked to sociodemographic data for 1990-2002 from population registers using unique personal identifiers. We examined trends in causes of death amenable to intervention in primary or specialist healthcare by income quintiles. RESULTS: Between 1992 and 2003, amenable mortality fell from 93 to 64 per 100,000 in men and 74 to 54 per 100,000 in women, an average annual decrease in amenable mortality of 3.6% and 3.1% respectively. Over this period, all cause mortality declined less, by 2.8% in men and 2.5% in women. By 2002-2003, amenable mortality among men in the highest income group had halved, but the socioeconomic gradient had increased as amenable mortality reduced at a significantly slower rate for men and women in the lowest income quintile. Compared to men and women in the highest income quintile, the risk ratio for mortality amenable to primary care had increased to 14.0 and 20.5 respectively, and to 8.8 and 9.36 for mortality amenable to specialist care. CONCLUSIONS: Our findings demonstrate an increasing socioeconomic gradient in mortality amenable to intervention in primary and specialist care. This is consistent with the existing evidence of inequity in healthcare use in Finland and provides supporting evidence of changes in the socioeconomic gradient in health service use and in important outcomes. The potential adverse effect of healthcare reform on timely access to effective care for people on low incomes provides a plausible explanation that deserves further attention.

How does a history of psychiatric hospital care influence access to coronary care: a cohort study.

OBJECTIVES: Equity in physical health of patients with severe mental disorders is a major public health concern. The aim of this cohort study was to examine equity in access to coronary care among persons with a history of severe mental disorder in 1998-2009. DESIGN: Nationwide register linkage cohort study. SETTING: Hospital care in the Finnish healthcare system. POPULATION: The study population consisted of all residents in Finland aged 40 years or older. All hospital discharges in 1998-2009 with a diagnosis of coronary heart disease or severe mental disorder were obtained from the Care Register. PRIMARY OUTCOME MEASURES: Data on deaths, hospitalisations and coronary revascularisations were linked to the data set using unique personal identifiers. RESULTS: Patients with severe mental disorders had increased likelihood of hospital care due to coronary heart disease (RR between 1.22, 95% CI 1.18 to 1.25 and 1.93, 1.84 to 2.03 in different age groups) and in 40-49-year-olds also increased likelihood of revascularisation (1.26, 1.16 to 1.38) compared with persons without mental disorders. Access to revascularisation was poorer among older persons with severe mental disorders in relation to need suggested by increased coronary mortality. In spite of excess coronary mortality (ranging from 0.95, 0.89 to 1.01 to 3.16, 2.82 to 3.54), worst off were people with a history of psychosis, who did not have increased use of hospital care and had lower likelihood of receiving revascularisations (ranging from 0.44, 0.37 to 0.51 to 0.74, 0.59 to 0.93) compared with persons without mental disorders. CONCLUSIONS: Selective mechanisms seem to be at work in access to care and revascularisations among people with severe mental disorders. Healthcare professionals need to be aware of the need for targeted measures to address challenges in provision of somatic care among people with severe mental health problems, especially among people with psychoses and old people.

Socio-economic predictors of mortality among diabetic people.

BACKGROUND: The present study examines the role of six aspects of socio-economic status (income, occupational position, education, unemployment, living alone and type of residential area) in mortality among types 1 and 2 diabetic people in Finland. All-cause mortality and causes of deaths (for example, alcohol diseases) are assessed. METHODS: People with diabetes aged 30-79 years in 2000-03 were identified from national registers. The data comprised 528 734 person-years and 18 841 deaths. Relative mortality risks were obtained from Poisson regression models. RESULTS: Among type 1 diabetic men, mortality differences were largest for long-term unemployed (aged 30-64 years); RR 3.85 (3.00-4.94) compared with the employed, and for low (vs. high) income group; RR 1.96 (1.78-2.17). The findings were similar for type 2 men; RR 2.58 (2.16-3.09) for unemployment and 1.61 (1.53-1.69) for income. In type 1 diabetic women, largest differences were found according to unemployment; RR 3.32 (1.88-5.88) and education (lowest vs. highest education); RR 2.35 (1.84-3.00), but in type 2 diabetes, the strongest determinants were disposable income; RR 1.55 (1.44-1.66) and education; RR 1.50 (1.33-1.70). In most socio-economic determinants, relative differences were largest in deaths due to diabetes and alcohol diseases. CONCLUSIONS: Five aspects of socio-economic position were related to mortality among diabetic people in Finland. No systematic mortality differences were, however, found for type of municipality of residence. These findings together with the role of deaths from alcohol diseases and diabetes in mortality trends, indicate that different aspects of social disadvantage are important predictors of mortality among diabetic people.

The burden of diabetes mortality in Finland 1988-2007 - a brief report.

BACKGROUND: Increasing incidence of diabetes has been reported in many countries and the disease burden related to diabetes to be distributed unevenly across the population. Patients with lower socioeconomic position have been reported to have higher diabetes prevalence, higher rates of diabetes related complications and excess mortality. This study examined trends in gender, age and socioeconomic differences in the burden of diabetes mortality in the Finnish population aged 35-80 and potential years of life lost (PYLL) due to diabetes. METHODS: The data consist of an 11% random sample of Finnish residents in 1987-2007 and an 80% oversample of persons who died during those years. We examined diabetes both as underlying and contributory cause. We calculated age-specific and age-standardized diabetes death rates by gender and socioeconomic position using the direct method and PYLL due to diabetes related deaths for 2004-2007. RESULTS: Diabetes related mortality was higher among older Finns. A clear and systematic socioeconomic pattern was detected among both men and women: the higher the socioeconomic position the lower the mortality. The contribution of diabetes to PYLL was 8% among men and 6% among women. Among women, the contribution of diabetes to PYLL was lower in higher socioeconomic groups, whereas among men, the contribution was similar in all socioeconomic groups. CONCLUSIONS: In order to further reduce the burden of diabetes a better treatment balance to prevent diabetes complications would significantly decrease the burden of diabetes mortality. Use of underlying and contributory causes of death is useful in monitoring trends and sub-group differences in the burden of diabetes.

Angina pectoris: relation of epidemiological survey to registry data.

BACKGROUND: Self-reported angina symptoms are collected in epidemiological surveys. We aimed at validating the angina symptoms assessed by the Rose Questionnaire against registry data on coronary heart disease. A further aim was to examine the sex paradox in angina implying that women report more symptoms, whereas men have more coronary events. DESIGN: Angina symptoms of 6601 employees of the City of Helsinki were examined using the postal questionnaire survey data combined with coronary heart disease registries. METHODS: The self-reported angina was classified as no symptoms, atypical pain, exertional chest pain, and stable angina symptoms. Reimbursed medications and hospital admissions were available from registries 10 years before the survey. Binomial regression analysis was used. RESULTS: Stable angina symptoms were associated with hospital admissions and reimbursed medications [prevalence ratio (PR), 6.75; 95% confidence interval (CI), 4.56-9.99]. In addition, exertional chest pain (PR, 5.31; 95% CI, 3.45-8.18) was associated with coronary events. All events were more prevalent among men than women (PR, 2.36; 95% CI, 1.72-3.25). CONCLUSION: The Rose Questionnaire remains a valid tool to distinguish healthy people from those with coronary heart disease. However, a notable part of those reporting symptoms have no confirmation of coronary heart disease in the registries. The female excess of symptoms and male excess of events may reflect inequality or delay in access to treatment, problems in identification and diagnosis, or more complex issues related to self-reported angina symptoms.

Increasing resources effected equity in access to revascularizations for patients with diabetes.

OBJECTIVES: To examine differences in access to coronary revascularization among a cohort of coronary patients with and without diabetes in 1995-2002 in Finland and to examine how rapidly increasing resources effected socioeconomic equity in access to these operations. DESIGN: An individual level nationwide register-based study of newly diagnosed CHD (coronary heart disease) patients (aged 40-79) in Finland. Rates for revascularizations were calculated per 1 000 person years. Socioeconomic differences were examined using Cox regression. RESULTS: Revascularization rates increased from 354 to 443 per 1 000 person years among men with CHD and from 301 to 366 among patients with diabetes. Among women with CHD the numbers were 224 and 249 and among patients with diabetes 208 and 325. Comparing trends for first revascularization between patient groups with and without diabetes differences increased somewhat among men. Among women, revascularization rates increased more among diabetic patients. Lower revascularization rates among lower socioeconomic groups were found throughout the study period in both patient groups. CONCLUSIONS: Simultaneously with large increase in cardiac operation rates, revascularization observed more common among women with diabetes compared to those without. However socioeconomic inequity in access to revascularizations among both genders remained even after increase in resources.