Geographic differentials in mortality of children in Mozambique: their implications for achievement of Millennium Development Goal 4.

In the light of Mozambique's progress towards the achievement of Millennium Development Goal 4 of reducing mortality of children aged less than five years (under-five mortality) by two-thirds within 2015, this study investigated the relationship between the province of mother's residence and under-five mortality in Mozambique, using data from the 2003 Mozambican Demographic and Health Survey. The analyses included 10,326 children born within 10 years before the survey. Results of univariate and multivariate analyses showed a significant association between under-five mortality and province (region) of mother's residence. Children of mothers living in the North provinces (Niassa, Cabo Delgado, and Nampula) and the Central provinces (Zambezia, Sofala, Manica, and Tete) had higher risks of mortality than children whose mothers lived in the South provinces, especially Maputo province and Maputo city. However, controlling for the demographic, socioeconomic and environmental variables, the significance found between the place of mother's residence and under-five mortality reduced slightly. This suggests that other variables (income distribution and trade, density of population, distribution of the basic infrastructure, including healthcare services, climatic and ecologic factors), which were not included in the study, may have confounding effects. This study supports the thought that interventions aimed at reducing under-five mortality should be tailored to take into account the subnational/regional variation in economic development. However, research is warranted to further investigate the potential determinants behind the observed differences in under-five mortality.

Socioeconomic differences in inpatient care expenditure in the last year of life among older people: a retrospective population-based study in Stockholm County.

OBJECTIVES: To investigate the association between inpatient care expenditure (ICE) and income group and the effect of demographic factors, health status, healthcare and social care utilisation on ICE in the last year of life. DESIGN: Retrospective population-based study. SETTING: Stockholm County. PARTICIPANTS: Decedents ≥65 years in 2015 (N=13 538). OUTCOME: ICE was calculated individually for the month of, and 12 months preceding death using healthcare register data from 2014 and 2015. ICE included the costs of admission and treatment in inpatient care adjusted for the price level in 2018. RESULTS: There were difference between income groups and ICE incurred at the 75th percentile, while a social gradient was found at the 95th percentile where the highest income group incurred higher ICE (SEK45 307, 95% CI SEK12 055 to SEK79 559) compared with the lowest income groups. Incurring higher ICE at the 95th percentile was driven by greater morbidity (SEK20 333, 95% CI SEK12 673 to SEK29 993) and emergency department care visits (SEK77 995, 95% CI SEK64 442 to SEK79 549), while lower ICE across the distribution was associated with older age and residing in institutional care. CONCLUSION: Gaining insight into patterns of healthcare expenditure in the last year of life has important implications for policy, particularly as socioeconomic differences were visible in ICE at a time of greater care need for all. Future policies should focus on engaging in advanced care planning and strengthening the coordination of care for older people.

Hospital deaths in Sweden: are individual socioeconomic factors relevant?

As the proportion of deaths in hospital falls, it is important to ensure that social disadvantage has no role in determining place of death. This study investigated the association between individual sociodemographic factors and deaths in hospitals for the population of Stockholm County, Sweden, using linked population registers. In 2002, 14,517 (87%) of the 16,617 adult decedents in Stockholm County had contact with health services in the three years before they died. Twenty-two percent (3,210) of these deaths were in hospitals. Individual income, education, country of birth, and gender had no influence on likelihood of hospital death in multivariate analyses. Decedent characteristics associated with higher chance of hospital death included older age, being married, diagnosis of heart disease, and contact with ambulatory services (not family practitioners) in the three years before death. Cancer patients were no more or less likely than those without cancer to die in hospital. In health systems wishing to reduce an already low proportion of deaths in acute hospitals, enhancing palliative and social support for older patients and people with noncancer diagnoses may merit attention.

Inequality in the face of death? Public expenditure on health care for different socioeconomic groups in the last year of life.

OBJECTIVE: To investigate the association between public expenditure on health care in the last year of life and individual socioeconomic status in Sweden. METHODS: Population-based study of public expenditure using linked registers for all 16,617 deaths among Stockholm County Council residents in 2002 (population 1.8 million). Age-standardized, total and per capita spend were calculated by income categories, age and specialty. Multivariate analysis examined the association between socioeconomic status and public expenditure. RESULTS: County council expenditure on health care in the last year of life rose with increasing income of the deceased person. Median per capita expenditure increased from 55,417 Swedish Kronor (SEK) (US$ 7542) in the lowest income group to SEK 94,678 (US$ 12,887) in the highest. Total age-standardized spend increased by 60% across the same interval (80,227 [95% confidence interval (CI) 79,946-80,497] to SEK 127,344 [95% CI 126,969-127,719]). Expenditure decreased with increasing age over 65 years in all income groups. Higher income was independently associated with greater total public health spend in multivariate analysis, adjusting for age, sex, health-care utilization and major diagnostic groups. CONCLUSIONS: There is inequality in public expenditure on health care at the end of life across socioeconomic groups in Stockholm. This phenomenon merits attention within Sweden, and beyond, in countries with less comprehensive welfare systems.

Inequalities in avoidable hospitalisation by area income and the role of individual characteristics: a population-based register study in Stockholm County, Sweden.

BACKGROUND: Avoidable hospitalisations are hospital admissions for medical conditions that could potentially have been prevented by outpatient healthcare. They are used as an indicator of access to and quality of primary healthcare. AIM: To investigate the association between median area income and avoidable hospitalisation and whether potential differences can be explained by contextual or compositional factors. METHOD: Median area income was calculated for all 43 city districts and municipalities in Stockholm County during 2005-2007 and grouped into quintiles. The association between median area income and avoidable hospitalisation was studied by calculating age-adjusted rates. To disentangle contextual and compositional effects, ORs with 95% CIs were calculated, controlling for individual age, sex, country of birth, marital status and socioeconomic position. RESULTS: Rates of avoidable hospitalisation were higher in areas with lower income, 1535 per 100 000 inhabitants in the lowest area income quintile compared with 1179 in the highest area income quintile after age standardisation. For the age group 18-64 years, comparing the lowest quintile with the highest quintile, adjustment for individual characteristics of residents (compositional factors) reduced the crude OR from 1.52 (95% CI 1.44 to 1.60) to 1.12 (95% CI 1.06 to 1.19). For the age group 65-79 years, the ORs were 1.28 (1.21 to 1.36) and 1.06 (1.00 to 1.13), respectively. For those aged 80+ years, no association was found with area median income. CONCLUSIONS: Higher rates of avoidable hospitalisation in low-income areas indicate greater healthcare needs of people living there. This should be addressed by investing in outpatient care for lower socioeconomic groups. The composition of individuals must be considered when studying area characteristics and avoidable hospitalisation.

Time for a new budget allocation model for hospital care in Stockholm?

In Stockholm County Council (SLL), budgets for hospital care have been allocated to geographically responsible authorities for a long time. This hospital care includes all publicly financed specialist care, also privately owned hospitals, except private practitioner care. The old needs-index model, a 6D capitation matrix based on demography and socio-economy, was generated on linked individual data for 1994-96. In this paper the power of the old allocation model is evaluated by the use of new data for 2006. The analysis shows that most of the socioeconomic variables have lost their descriptive power in 10 years. Using a methodical search we also find an improved need-based allocation model for hospital care using the new data for 2006. By focusing on costly diagnoses, where the descriptive power has increased between 1996 and 2006, and by using some new socioeconomic variables, and by relying on birth and death prognoses, we are able to generate a matrix model with much higher coefficients-of-determinations in 1 year predictions. In addition, a more careful modelling of multi-morbidity, part-of-the-year inhabitants, episode definition and cost transformation is developed. The area-level cost residuals of registered versus predicted costs show stable signs over the years, indicating unexplained systematics. For the reduction of the residuals, accepting proven inpatient diagnoses but not the full costs, a mixed capitation/fee-for-service strategy is discussed. Once equivalent (e.g. full-year) observations are determined, the link between background and consumption is not on individual-level but on cell-level, as in current resource allocation studies in the United Kingdom.