Correction to: Socioeconomic inequalities in suicide mortality before and after the economic recession in Spain.

It has been highlighted that the original article.

Gender and socioeconomic inequalities in the implementation of the Basque programme for multimorbid patients.

BACKGROUND: The aim of our study was to increase awareness of the relevance of the implemented programmes to inequity of access and inequality of health by analyzing the impact of a patient-centred strategy for multimorbid patients. METHODS: This retrospective study compared the 2014 multimorbid patient group (intervention group) with its 2012 analogue (control group), before the Department of Health of the Basque Country launched the strategy for managing disease chronicity. Inequalities in healthcare access were represented by differences in the inclusion of patients in the programme and in contacts with primary care (PC) services by gender and socioeconomic status (measured by deprivation index by census track). Likewise, differences in hospital care represented inequalities in health outcomes. Generalized linear models were used to analyze relationships among variables. A propensity score by a genetic matching approach was used to minimize possible selection bias. RESULTS: At baseline, women had less probability of being eligible for the programme. No clear patterns were seen in resource consumption in PC. The probability of hospitalization was higher for men and increased according to socioeconomic status. The implementation of the programme yielded more contacts with PC services in all groups and a reduction in hospitalizations, especially among men and the most socioeconomically deprived patients. CONCLUSION: The patient-centred, integrated-care intervention launched by the Department of Health of the Basque Country might have reduced some gender and socioeconomic inequalities in health outcomes, as it avoided more hospitalizations in subgroups that presented with more episodes of decompensation in the reference year.

Socioeconomic inequalities in suicide mortality before and after the economic recession in Spain.

BACKGROUND: An increase in suicide mortality is often observed in economic recessions. The objective of this study was to analyse trends in socioeconomic inequalities in suicide mortality before and during the economic recession in two geographical settings in Spain. METHODS: This study analyses inequalities in mortality according to educational level during 3 different time periods based on individual data from the Basque Country and Barcelona city. We analysed suicide mortality data for all residents over 25 years of age from 2001 to 2012. Two periods before the crisis (2001-2004 and 2005-2008) and another during the crisis (2009-2012) were studied. We performed independent analyses for sex, age group, and for the two geographical settings. We fit Poisson regression models to study the relationship between educational level and mortality, and calculated the relative index of inequality (RII) and the slope index of inequality (SII) as comparative measures. RESULTS: For men in the Basque Country, all RII values for the three time periods were similar and almost all were greater than 2; in Barcelona the RII values were generally lower. The SII values for Barcelona tended to decrease over time, whereas in the Basque Country they showed a U-shaped pattern. Among women aged 25-44 years we found an association between educational level and suicide mortality during the first time period; however, we found no clear association for other age groups or time periods. CONCLUSION: This study within two geographical settings in Spain shows that trends in inequalities in suicide mortality according to educational level remained stable among men before and during the economic recession.

The impact of the Great Recession on mental health and its inequalities: the case of a Southern European region, 1997-2013.

BACKGROUND: Numerous studies have shown that macroeconomic changes have a great influence on health, prompting different concerns in recent literature about the effects of the current recession. The objective of the study was to assess the changes in the mental health of the working-age population in the Basque Country (Spain) and its social inequalities following the onset of the 2008 recession, with special focus on the role of unemployment. METHODS: Repeated cross-sectional study on the population aged 16-64, using four Basque Health Surveys (1997-2013). Age-adjusted prevalences of poor mental health and incremental prevalence ratios (working status and social class adjusted) between years were calculated. Absolute/relative measures of social inequalities were also calculated. RESULTS: From 2008, there was a clear deterioration in the mental health, especially among men. Neither changes in employment status nor social class accounted for these changes. In men, the deterioration affected all working status categories, except the retired but significant changes occurred only among the employed. In women, poor mental health significantly increased among the unemployed. Students were also especially affected. Relative inequalities increased only in men. CONCLUSIONS: The Great Recession is being accompanied by adverse effects on mental health, which cannot be fully explained by the increase of unemployment. Public health professionals should closely monitor the medium and long-term effects of the crisis as these may emerge only many years after the onset of recessions.

Marital status, labour force activity and mortality: a study in the USA and six European countries.

AIMS: Labour force activity and marriage share some pathways through which they potentially influence health. In this paper, we examine whether marriage and labour force participation interact in the way they influence mortality in the USA and six European countries. METHODS: We used data from the US National Health Interview Survey linked to the National Death Index, and national mortality registry data for Austria, England/Wales, Finland, Hungary, Norway and Spain (specifically, the Basque country) during 1999-2007, for men and women aged 30-59 years at baseline. We used Poisson regression to estimate both the additive (relative excess risk due to interaction) and multiplicative interactions between marriage and labour force activity on mortality. RESULTS: Labour force inactivity was associated with higher mortality, but this association was stronger for unmarried, rather than married, individuals. Likewise, being unmarried was associated with higher mortality, but this association was stronger for inactive than for active individuals. To illustrate, among US women out of the labour force, being unmarried was associated with a 3.98 times (95%CI 3.28-4.82) higher risk of dying than being married; whereas the relative risk (RR) was 2.49 (95%CI 2.10-2.94), for women who were active in the labour market. Although this interaction between marriage and labour force activity was only significant for women on a multiplicative scale, there was a significant additive interaction for both men and women. The pattern was similar across all countries. CONCLUSIONS: Marriage attenuated the increased mortality risk associated with labour force inactivity; while labour force activity attenuated the mortality risk associated with being unmarried. Our study emphasizes the importance of public health and social policies that improve the health and well-being of unmarried and inactive men and women.

Changes in social inequalities in disability-free life expectancy in Southern Europe: the case of the Basque Country.

BACKGROUND: Health expectancy is a useful tool to monitor health inequalities. The evidence about the recent changes in social inequalities in healthy expectancy is relatively scarce and inconclusive, and most studies have focused on Anglo-Saxon and central or northern European countries. The objective of this study was to analyse the changes in socioeconomic inequalities in disability-free life expectancy in a Southern European population, the Basque Country, during the first decade of the 21st century. METHODS: This was an ecological cross-sectional study of temporal trends on the Basque population in 1999-2003 and 2004-2008. All-cause mortality rate, life expectancy, prevalence of disability and disability free-life expectancy were calculated for each period according to the deprivation level of the area of residence. The slope index of inequality and the relative index of inequality were calculated to summarize and compare the inequalities in the two periods. RESULTS: Disability free-life expectancy decreased as area deprivation increased both in men and in women. The difference between the most extreme groups in 2004-2008 was 6.7 years in men and 3.7 in women. Between 1999-2003 and 2004-2008, socioeconomic inequalities in life expectancy decreased, and inequalities in disability-free expectancy increased in men and decreased in women. CONCLUSIONS: This study found important socioeconomic inequalities in health expectancy in the Basque Country. These inequalities increased in men and decreased in women in the first decade of the 21st century, during which the Basque Country saw considerable economic growth.

Trends in socioeconomic inequalities in ischemic heart disease mortality in small areas of nine Spanish cities from 1996 to 2007 using smoothed ANOVA.

The aim of this study was to analyze the evolution of socioeconomic inequalities in mortality due to ischemic heart diseases (IHD) in the census tracts of nine Spanish cities between the periods 1996-2001 and 2002-2007. Among women, there are socioeconomic inequalities in IHD mortality in the first period which tended to remain stable or even increase in the second period in most of the cities. Among men, in general, no socioeconomic inequalities have been detected for this cause in either of the periods. These results highlight the importance of intra-urban inequalities in mortality due to IHD and their evolution over time.

Why does Spain have smaller inequalities in mortality? An exploration of potential explanations.

BACKGROUND: While educational inequalities in mortality are substantial in most European countries, they are relatively small in Spain. A better understanding of the causes of these smaller inequalities in Spain may help to develop policies to reduce inequalities in mortality elsewhere. The aim of the present study was therefore to identify the specific causes of death and determinants contributing to these smaller inequalities. METHODS: Data on mortality by education were obtained from longitudinal mortality studies in three Spanish populations (Barcelona, Madrid, the Basque Country), and six other Western European populations. Data on determinants by education were obtained from health interview surveys. RESULTS: The Spanish populations have considerably smaller absolute inequalities in mortality than other Western European populations. This is due mainly to smaller inequalities in mortality from cardiovascular disease (men) and cancer (women). Inequalities in mortality from most other causes are not smaller in Spain than elsewhere. Spain also has smaller inequalities in smoking and sedentary lifestyle and this is due to more smoking and physical inactivity in higher educated groups. CONCLUSION: Overall, the situation with regard to health inequalities does not appear to be more favourable in Spain than in other Western European populations. Smaller inequalities in mortality from cardiovascular disease and cancer in Spain are likely to be related to its later socio-economic modernization. Although these smaller inequalities in mortality seem to be a historical coincidence rather than the outcome of deliberate policies, the Spanish example does suggest that large inequalities in total mortality are not inevitable.

Two decades of inequalities in smoking prevalence, initiation and cessation in a southern European region: 1986-2007.

BACKGROUND: The smoking epidemic is still progressing in southern Europe. We aimed to analyse the magnitude and trend of social inequalities in smoking prevalence, initiation and cessation in the Basque Country, a southern European region, from 1986 to 2007, determining the patterns by sex and age. METHODS: This was a cross-sectional time trend study on the population aged >24 years using the Basque Country Health Surveys of 1986, 1992, 1997, 2002 and 2007. Age-adjusted prevalence of current and ever smoking and cessation were calculated, as were relative index of inequality and population-attributable risk by occupational social class and educational level. Relative risk of starting smoking was estimated using Cox proportional hazard regression models. Calculations were performed separately by sex and for two age groups (25-44 years and >44 years). RESULTS: Men and young women in the Basque Country have evolved towards the last stage of the epidemic, with an increasing concentration of smoking in disadvantaged groups, by educational level, especially among the youngest population. In older women, smoking continues rising, especially among higher socio-economic groups, though differences between groups are diminishing. The role of initiation and cessation inequalities as determinants of smoking inequalities differed considerably by age and sex. CONCLUSION: Inequalities in smoking prevalence widened from 1986 to 2007 in the Basque Country, especially among the youngest population. The changing pattern of these inequalities and the different roles of initiation and cessation dynamics need to be taken into account to improve the results of tobacco control policies and their effect on smoking inequalities.

Association of proximity to polluting industries, deprivation and mortality in small areas of the Basque Country (Spain).

BACKGROUND: The study is aimed at assessing social inequities in the location of polluting industries in the Basque Country, and at exploring if the effect on mortality of living near air polluting industries is modified by economic deprivation. METHODS: This is a cross-sectional ecological study that uses the census sections as analysis units. Mortality from all causes, lung cancer, respiratory diseases and ischaemic heart disease were studied. Ordinal logistic regression models were fitted to assess if proximity of census sections to polluting industries is associated with deprivation. Bayesian Poisson regression models were used to explore if the association between proximity to polluting industries and mortality is modified by socio-economic deprivation. RESULTS: Proximity to a polluting industry and deprivation are positively associated, showing a clear gradient across deprivation quintiles. In women, the risk associated with proximity to metal-processing industries grows as the deprivation of the area increases in the case of total and lung cancer mortality. In men, the interaction terms between proximity and deprivation are positive for total, ischaemic heart disease mortality, with a credibility level approaching 90%. High levels of deprivation are associated with greater risk of mortality, excepting lung cancer in women. CONCLUSION: There is a higher proportion of more deprived census sections around polluting industries in the Basque Country. Risks of mortality associated with proximity to polluting industries tend to be higher in more deprived areas.

Predictive risk modelling in the Spanish population: a cross-sectional study.

BACKGROUND: An increase in chronic conditions is currently the greatest threat to human health and to the sustainability of health systems. Risk adjustment systems may enable population stratification programmes to be developed and become instrumental in implementing new models of care.The objectives of this study are to evaluate the capability of ACG-PM, DCG-HCC and CRG-based models to predict healthcare costs and identify patients that will be high consumers and to analyse changes to predictive capacity when socio-economic variables are added. METHODS: This cross-sectional study used data of all Basque Country citizens over 14 years of age (n = 1,964,337) collected in a period of 2 years. Data from the first 12 months (age, sex, area deprivation index, diagnoses, procedures, prescriptions and previous cost) were used to construct the explanatory variables. The ability of models to predict healthcare costs in the following 12 months was assessed using the coefficient of determination and to identify the patients with highest costs by means of receiver operating characteristic (ROC) curve analysis. RESULTS: The coefficients of determination ranged from 0.18 to 0.21 for diagnosis-based models, 0.17-0.18 for prescription-based and 0.21-0.24 for the combination of both. The observed area under the ROC curve was 0.78-0.86 (identifying patients with a cost higher than P-95) and 0.83-0.90 (P-99). The values of the DCG-HCC models are slightly higher and those of the CRG models are lower, although prescription information could not be used in the latter. On adding previous cost data, differences between the three systems decrease appreciably. Inclusion of the deprivation index led to only marginal improvements in explanatory power. CONCLUSION: The case-mix systems developed in the USA can be useful in a publicly financed healthcare system with universal coverage to identify people at risk of high health resource consumption and whose situation is potentially preventable through proactive interventions.

Monitoring the prevalence of chronic conditions: which data should we use?

BACKGROUND: Chronic diseases are an increasing threat to people's health and to the sustainability of health organisations. Despite the need for routine monitoring systems to assess the impact of chronicity in the population and its evolution over time, currently no single source of information has been identified as suitable for this purpose. Our objective was to describe the prevalence of various chronic conditions estimated using routine data recorded by health professionals: diagnoses on hospital discharge abstracts, and primary care prescriptions and diagnoses. METHODS: The ICD-9-CM codes for diagnoses and Anatomical Therapeutic Chemical (ATC) codes for prescriptions were collected for all patients in the Basque Country over 14 years of age (n=1,964,337) for a 12-month period. We employed a range of different inputs: hospital diagnoses, primary care diagnoses, primary care prescriptions and combinations thereof. Data were collapsed into the morbidity groups specified by the Johns Hopkins Adjusted Clinical Groups (ACGs) Case-Mix System. We estimated the prevalence of 12 chronic conditions, comparing the results obtained using the different data sources with each other and also with those of the Basque Health Interview Survey (ESCAV). Using the different combinations of inputs, Standardized Morbidity Ratios (SMRs) for the considered diseases were calculated for the list of patients of each general practitioner. The variances of the SMRs were used as a measure of the dispersion of the data and were compared using the Brown-Forsythe test. RESULTS: The prevalences calculated using prescription data were higher than those obtained from diagnoses and those from the ESCAV, with two exceptions: malignant neoplasm and migraine. The variances of the SMRs obtained from the combination of all the data sources (hospital diagnoses, and primary care prescriptions and diagnoses) were significantly lower than those using only diagnoses. CONCLUSIONS: The estimated prevalence of chronic diseases varies considerably depending of the source(s) of information used. Given that administrative databases compile data registered for other purposes, the estimations obtained must be considered with caution. In a context of increasingly widespread computerisation of patient medical records, the complementary use of a range of sources may be a feasible option for the routine monitoring of the prevalence of chronic diseases.

Cancer mortality inequalities in urban areas: a Bayesian small area analysis in Spanish cities.

BACKGROUND: Intra-urban inequalities in mortality have been infrequently analysed in European contexts. The aim of the present study was to analyse patterns of cancer mortality and their relationship with socioeconomic deprivation in small areas in 11 Spanish cities. METHODS: It is a cross-sectional ecological design using mortality data (years 1996-2003). Units of analysis were the census tracts. A deprivation index was calculated for each census tract. In order to control the variability in estimating the risk of dying we used Bayesian models. We present the RR of the census tract with the highest deprivation vs. the census tract with the lowest deprivation. RESULTS: In the case of men, socioeconomic inequalities are observed in total cancer mortality in all cities, except in Castellon, Cordoba and Vigo, while Barcelona (RR = 1.53 95%CI 1.42-1.67), Madrid (RR = 1.57 95%CI 1.49-1.65) and Seville (RR = 1.53 95%CI 1.36-1.74) present the greatest inequalities. In general Barcelona and Madrid, present inequalities for most types of cancer. Among women for total cancer mortality, inequalities have only been found in Barcelona and Zaragoza. The excess number of cancer deaths due to socioeconomic deprivation was 16,413 for men and 1,142 for women. CONCLUSION: This study has analysed inequalities in cancer mortality in small areas of cities in Spain, not only relating this mortality with socioeconomic deprivation, but also calculating the excess mortality which may be attributed to such deprivation. This knowledge is particularly useful to determine which geographical areas in each city need intersectorial policies in order to promote a healthy environment.

[Deprivation index by enumeration district in Spain, 2011]. / Índice de privación en España por sección censal en 2011.

OBJECTIVE: To present the methodology used in the design and implementation of a deprivation index by enumeration district, and to describe the socioeconomic situation of Spain in 2011. METHOD: The unit of analysis was the enumeration district (N=35,960). Data came from the 2011 Population and Housing Census of Spain. Given both the sampling nature of the Census and the regulatory limitations of data confidentiality, variables were calculated indirectly by using the complement of the available variables. Checks were made to ensure reliability. The selection of the indicators took into account comparability with the MEDEA index. The inclusion of additional information was explored. A deprivation index was built using Principal Component Analysis. Sensitivity analysis of the index was performed for urban areas and the rest of the regions. RESULTS: Using the census information, 22 indicators were calculated for 35,917 enumeration districts. The deprivation index was based on six indicators: manual and temporary workers, unemployment, insufficient education overall and in young people (aged 16 to 29 years), and dwellings without access to the internet. The map of Spain shows a gradient of decreasing deprivation from south-west to north-east. CONCLUSIONS: The socioeconomic information of the 2011 census by enumeration district was used systematically. The drafted index, similar to the MEDEA, will facilitate the updated study of health inequalities for Spain overall following the economic recession that began in 2008.

[Effect of the population in collective dwellings on small-area mortality risk estimation in the Basque Country region (Spain)]. / Efecto producido por la población institucionalizada en la estimación del riesgo de mortalidad en áreas pequeñas de Euskadi (España).

OBJECTIVE: To quantify the effect of the inclusion of the population in collective dwellings on the estimation of mortality risk in the census areas of the Basque Country (Spain) for the main causes of mortality in the period 1996-2003. METHOD: Small-area ecological cross-sectional study. The main causes of mortality by sex were analyzed. RESULTS: When the general effect on all areas with a a population in collective dwellings was analyzed, hardly any noticeable effect was seen on either men or women. On the other hand, an effect was found when selecting the areas where the population in collective dwellings is more than 10% of the area's population. CONCLUSIONS: The effect of the inclusion of the population in collective dwellings clearly seen in causes of mortality, such as dementia and Alzheimer's disease, and in chronic obstructive pulmonary disease, related to greater dependence or frailty, and therefore related to being in a nursing or elderly persons' home, over-estimating the risk of mortality by approximately 8% and 4%, respectively, in these geographical areas.

[Health impact assessment: a tool to incorporate health into non-sanitary interventions]. / La evaluación del impacto sobre la salud: una herramienta para incorporar la salud en las intervenciones no sanitarias.

Interventions implemented by governments are very frequently related to the determinants of health. Health impact assessment (HIA) is used as a predictive tool to include health in nonhealth policymaking. This paper defines HIA, describes its methods, procedures and applications, and discusses opportunities and challenges associated with HIA. Doing a HIA implies studying the intervention, profiling the target population, and estimating its impacts on health by means of combining quantitative and qualitative evidence. HIA has been used in different kinds of policies (transports, urban regeneration, culture, energy development etc.), at different levels (local, national, European) and in many countries. Despite its scarce use in Spain, HIA allows to consider health in sectorial policymaking, taking into account social inequalities in health, so that healthier public policies can be designed. On the other hand, HIA is a tool under methodological development which use is hindered due to the existing narrow biomedical perspective on the determinants of health, and to the difficulties in working in public policy-making with multisectorial and participative perspectives.

[Small area estimation of health indicators based on data from the Basque Country Health Survey]. / Estimación de indicadores de salud en áreas pequeñas a partir de datos de la Encuesta de Salud de Euskadi.

Health surveys are a key tool for decision-making in health policies and health services planning. The use of small-area statistical methods that use information at different geographic levels may be useful for estimating health indicators at a lower geographical level than originally considered in the survey design.

Stable socioeconomic inequalities in ischaemic heart disease mortality during the economic crisis: a time trend analysis in 2 Spanish settings.

BACKGROUND: Prior studies have identified a decrease in ischaemic heart disease mortality during the recent economic recession. The Spanish population was severely affected by the Great Recession, however, there is little evidence on its effects on socioeconomic inequalities in ischaemic heart disease mortality. This study examines trends in socioeconomic inequalities in mortality due to ischaemic heart disease (IHD). METHODS: We used linked census records with mortality registers available from the Basque Country and Barcelona city for population above 25 years, between 2001 and 04, the accelerated economic growth period of 2005-08, and 2009-12, with the last period coinciding with the Great Recession. Applying Poisson models, we calculated relative and absolute indexes of inequalities by education level for each period, age group, gender, and site. RESULTS: We found moderate age-adjusted inequalities in IHD with a gradient of increasing rates through less educational level, but no significant evidence of increasing trends in socioeconomic inequalities in IHD mortality, rather an inverted U-shape time trend in some groups below 75 years in relative inequalities. Absolute inequalities decrease in the last period except for women from 50 to 64 years. CONCLUSIONS: This study shows that the economic crisis has not increased socioeconomic inequalities in IHD mortality in two geographical settings in Spain.

[Constructing a deprivation index based on census data in large Spanish cities(the MEDEA project)]. / Construcción de un índice de privación a partir de datos censales en grandes ciudades españolas (Proyecto MEDEA).

OBJECTIVES: a) To describe the methodology used to construct a deprivation index by census tract in cities, to identify the tracts with the least favorable socioeconomic conditions, and b) to analyze the association between this index and overall mortality. METHODS: Several socioeconomic indicators (Census 2001) were defined by the census tracts of the following cities: Barcelona, Bilbao, Madrid, Seville and Valencia. The correlations with the standardized mortality ratio (1996-2003), and the dimensionality of the socioeconomic indicators were studied. Finally, the selected indicators were aggregated in an index, in which the results of the factor loadings from extraction of a factor by principal components were used as weighting values. RESULTS: The indicators with the strongest correlations with overall mortality were those related to work, education, housing conditions and single parent homes. In the analysis of dimensionality, a first dimension appeared that contained indicators related to work (unemployment, manual and eventual workers) and education (insufficient education overall and in young people). In all the cities studied, the index created with these 5 indicators explained more than 75% of their variability. The correlations between this index and mortality generally showed higher values than those obtained with each indicator separately. CONCLUSIONS: The deprivation index proposed could be a useful instrument for health planning as it detects small areas of large cities with unfavorable socioeconomic characteristics and is associated with mortality. This index could contribute to the study of social inequalities in health in Spain.

[Gender differences in early reperfusion treatment after myocardial infarction]. / Diferencias de género en el tratamiento de revascularización precoz del infarto agudo de miocardio.

BACKGROUND AND OBJECTIVE: Clinical variability in myocardial infarction (MI) regarding age, comorbidities and atypical symptoms could determine gender differences in inhospital care. This study analyzes the magnitude and determinants of differences between men and women in early reperfusion therapy in people hospitalized after MI. PATIENTS AND METHOD: 2,836 patients who arrived to hospital with MI were studied (IBERICA-Basque Country study). The relative risk (RR) of receiving early reperfusion for men versus women, adjusted by age, clinical characteristics, risk factors, and pre-hospital delay was estimated. The effect decomposition methodology and the log binomial regression were applied. RESULTS: 29% of patients were women with a median age of 77 years. The RR of revascularization in men compared to women was different according to age. When factors such as hypertension diabetes, Killip III-IV at admission and atypical symptoms were taken into account, statistically significant differences between sexes were not detected at 45 years old (RR=0.91; 95% CI=0.77-1.07). However, for 64 years old and over, the RR of reperfusion was 1.24 (95% CI=1.05-1.47). Both the differences by sex and the sex-age interaction were no longer statistically significant after adjusting by pre-hospital delay. CONCLUSIONS: The delay to receive medical care in elderly women is responsible of gender differences in early reperfusion. It is necessary to analyze the reasons for treatment-seeking delay.