Cristina Masseria

Measuring Socioeconomic Differences in Use of Health Care Services by Wealth Versus by Income

OBJECTIVES We compared the extent of socioeconomic differences in use of health care services based on wealth (i.e., accumulated assets) as the socioeconomic ranking variable with the extent of differences based on income to explore the sensitivity of the estimates of equity to the choice of the socioeconomic indicator. METHODS We used data from the Health and Retirement Study in the United States and the Survey of Health, Ageing, and Retirement in Europe to estimate levels of income- and wealth-related disparity in use of physician and dental services among adults 50 or older in 12 countries. RESULTS We found socioeconomic differences in use of physician services after standardizing for need in about half of the countries studied. No consistent pattern in levels of disparity measured by wealth versus those measured by income was found. However, the rich were significantly more likely to use dental services in all countries. Wealth-related differences in dental service use were consistently higher than were income-related differences. CONCLUSIONS We found some support for wealth as a more sensitive indicator of socioeconomic status among older adults than was income. Wealth may thus allow more accurate measurements of socioeconomic differences in use of health care services for this population.

The socio-economic determinants of the health status of Roma in comparison with non-Roma in Bulgaria, Hungary and Romania

BACKGROUNDS Roma people from Central and Eastern Europe suffer some of the worst health conditions in the industrialized world. This article aims at identifying the determinants of health status among Roma in comparison with non-Roma in Bulgaria, Romania and Hungary. METHODS Non-linear models were estimated for three different health indicators: self-reported health compared with the previous year, probability of reporting chronic conditions and feeling threatened by illness because of sanitary and hygienic circumstances. Ethnic origin differentiated by Roma, national population and other ethnic minorities is self-reported. The data used are from a unique data set provided by the United Nations Development Programme household survey on Roma and populations living in their close proximity for 2004. Sample sizes are 2536 for Bulgaria, 2640 for Hungary and 3292 for Romania. RESULTS After controlling for demographic variables the Roma were significantly more likely to report worse health in any indicator than the non-Roma everywhere. However, after including socio-economic variables, Roma had a significantly higher probability of reporting chronic conditions only in Romania. For the probability of feeling threatened by illness because of unhygienic circumstances, being Roma was a main determinant in Hungary and Romania, but not in Bulgaria. The results for self-reported health were inconclusive. CONCLUSIONS While these results in part support the development of health policies targeting Roma, the finding that poorly educated and less wealthy people, as well as other ethnic minorities also experience health inequalities suggests that broader multisectoral policies are needed in the countries studied.

Equity in access to health care in Italy: a disease-based approach.

BACKGROUND Equitable access to health care is a core objective of the Italian health care system. Despite having achieved universal coverage for a fairly comprehensive set of health services for decades, there is still evidence of inequities systematically associated with income. METHOD Income-related inequity indices were estimated for the probability of general practitioner (GP), specialist, inpatient care and also emergency care using a variety of need indicators. The data used were the Multiscopo survey, 2000 matched with the European Community Household Panel survey for Italy. The contribution of regional inequality was also estimated. Horizontal inequity indices for health care utilization measures were computed separately for people reporting hypertension, arthritis, tumour and heart disease. RESULTS Significant pro-rich income related inequity was found for GP, specialist and emergency care, no inequity was found for inpatient care. The disease approach showed statistically significant inequity in the probability of specialist care in three of the four chronic conditions analysed, and pro-poor inequity in GP care for all conditions. Inequity was mainly caused by income and regional variations. CONCLUSIONS By reducing regional variation it would be possible to significantly reduce the pro-rich inequity in GP, specialist and emergency care. For specialist care inequity was found for the overall adult population and also among people with serious chronic conditions, and was caused not only by income and regional variation, but also by educational attainment and insurance.

Cost-Effectiveness of Tdap Vaccination of Adults Aged ≥65 Years in the Prevention of Pertussis in the US: A Dynamic Model of Disease Transmission

Objectives In February 2012, the Advisory Committee on Immunization Practices (ACIP) advised that all adults aged ≥65 years receive a single dose of reduced-antigen-content tetanus, diphtheria, and acellular pertussis (Tdap), expanding on a 2010 recommendation for adults >65 that was limited to those with close contact with infants. We evaluated clinical and economic outcomes of adding Tdap booster of adults aged ≥65 to “baseline” practice [full-strength DTaP administered from 2 months to 4–6 years, and one dose of Tdap at 11–64 years replacing decennial Td booster], using a dynamic model. Methods We constructed a population-level disease transmission model to evaluate the cost-effectiveness of supplementing baseline practice by vaccinating 10% of eligible adults aged ≥65 with Tdap replacing the decennial Td booster. US population effects, including indirect benefits accrued by unvaccinated persons, were estimated during a 1-year period after disease incidence reached a new steady state, with consequences of deaths and long-term pertussis sequelae projected over remaining lifetimes. Model outputs include: cases by severity, encephalopathy, deaths, costs (of vaccination and pertussis care) and quality-adjusted life-years (QALYs) associated with each strategy. Results in terms of incremental cost/QALY gained are presented from payer and societal perspectives. Sensitivity analyses vary key parameters within plausible ranges. Results For the US population, the intervention is expected to prevent >97,000 cases (>4,000 severe and >5,000 among infants) of pertussis annually at steady state. Additional vaccination costs are

Equity in health care use among older people in the UK: an analysis of panel data

4.7 million. Net cost savings, including vaccination costs, are

Cost-Effectiveness Analysis of Tdap in the Prevention of Pertussis in the Elderly

47.7 million (societal perspective) and

Vaccine Timeliness: A Cost Analysis of the Potential Implications of Delayed Pertussis Vaccination in the US.

44.8 million (payer perspective). From both perspectives, the intervention strategy is dominant (less costly, and more effective by >3,000 QALYs) versus baseline. Results are robust to sensitivity analyses and alternative scenarios. Conclusions Immunization of eligible adults aged ≥65, consistent with the current ACIP recommendation, is cost saving from both payer and societal perspectives.

Health inequality: what does it mean and how can we measure it?

This article uses panel data to investigate the extent of income-related inequity in the likelihood of visiting a General Practitioner (GP), specialist, dentist and hospital among individuals aged 65 years and over in the UK. The probability of accessing health care is predicted with separate random effects probit panel models using data from the British Household Panel Survey (BHPS) for the period 1998 to 2006. We use well-established methods based on the concept of the concentration curve to compare the cumulative distribution of health care utilization with the cumulative distribution of the population ranked by income. The results find evidence for inequity in specialist and dental care, but only slight inequity for GP care and not significant inequity in hospital admissions. Levels of inequity are highest for specialist and dental care, even when users of the private sector are excluded from analyses. The Mobility Index (MI) is also used to compare short- and long-run estimates of inequities and show that upwardly income mobile individuals contribute to inequity in the long run.

Health in the European Union: trends and analysis

Objectives Health benefits and costs of combined reduced-antigen-content tetanus, diphtheria, and pertussis (Tdap) immunization among adults ≥65 years have not been evaluated. In February 2012, the Advisory Committee on Immunization Practices (ACIP) recommended expanding Tdap vaccination (one single dose) to include adults ≥65 years not previously vaccinated with Tdap. Our study estimated the health and economic outcomes of one-time replacement of the decennial tetanus and diphtheria (Td) booster with Tdap in the 10% of individuals aged 65 years assumed eligible each year compared with a baseline scenario of continued Td vaccination. Methods We constructed a model evaluating the cost-effectiveness of vaccinating a cohort of adults aged 65 with Tdap, by calculating pertussis cases averted due to direct vaccine effects only. Results are presented from societal and payer perspectives for a range of pertussis incidences (25–200 cases per 100,000), due to the uncertainty in estimating true annual incidence. Cases averted were accrued throughout the patient s lifetime, and a probability tree used to estimate the clinical outcomes and costs (US

Unmet need as an indicator of health care access.

2010) for each case. Quality-adjusted life-years (QALYs) lost to acute disease were calculated by multiplying cases of mild/moderate/severe pertussis by the associated health-state disutility; QALY losses due to death and long-term sequelae were also considered. Incremental costs and QALYs were summed over the cohort to derive incremental cost-effectiveness ratios. Scenario analyses evaluated the effect of alternative plausible parameter estimates on results. Results At incidence levels of 25, 100, 200 cases/100,000, vaccinating adults aged 65 years costs an additional