How did the recent increase in the supply of coronary operations in Finland affect socioeconomic and gender equity in their use?

STUDY OBJECTIVE: To explore how the increased supply of coronary bypass operations and angioplasties from 1988 to 1996 influenced socioeconomic and gender equity in their use. DESIGN: Register based linkage study; information on coronary procedures from the Finnish Hospital Discharge Register in 1988 and 1996 was individually linked to national population censuses in 1970-1995 to obtain patients' socioeconomic data. Data on both hospitalisations and mortality attributable to coronary heart disease obtained from similar linkage schemes were used to approximate the relative need of procedures in socioeconomic groups. SETTING: Finland, 2,094,846 inhabitants in 1988 and 2,401,027 in 1996 aged 40 years and older, and Discharge Register data from all Finnish hospitals offering coronary procedures in 1988 and 1996. MAIN RESULTS: The overall rate of coronary revascularisations in Finland increased by about 140% for men and 250% for women from 1988 to 1996. Over the same period, socioeconomic and gender disparities in operation rates diminished, as did the influence of regional supply of procedures on the extent of these differences. However, men, and better off groups in terms of occupation, education, and family income, continued to receive more operations than women and the worse off with the same level of need. CONCLUSIONS: Although revascularisations in Finland increased 2.5-fold overall, some socioeconomic and gender inequities persisted in the use of cardiac operations relative to need. To improve equity, a further increase of resources may be needed, and practices taking socioeconomic and gender equity into account should be developed for the referral of coronary heart disease patients to hospital investigations.     

Private medicine and socioeconomic differences in the rates of common surgical procedures in Finland

The aim of the study was to evaluate socioeconomic equity in access to surgical services in Finland and to explore the contribution of private sector procedures to any inequities. Data on nine common surgical procedures performed on patients aged 25 and over were obtained from the 1987-88 Finnish Hospital Discharge Register. Socioeconomic indicators were linked to the procedure data by personal identity numbers from the 1987 population census, which was also used to derive the data on population at risk. The study revealed marked differences in rates across socioeconomic categories for several procedures. Some of these disparities are probably explained by variations in need for surgery across socioeconomic groups. However, for cataract operations and hip replacements due to arthrosis or deformity, the surgery rates favoured the better-off, despite low social status being considered a risk factor for these disorders. The correlation or disposable family income with hysterectomy and prostatectomy rates, and the low surgery rates for many procedures in the lowest income quintile also suggested socioeconomic disparities in access to services. The specific effect of private sector seems to have contributed to the socioeconomic differences in rates for, at least, hysterectomy, prostatectomy, and cataract operations. Although the Finnish health care system operates universal coverage without formal barriers to equal access, systematic socioeconomic inequity in the use of individual surgical treatments prevail. Part of these inequities is evidently due to private sector services.     

Hysterectomy and socioeconomic position in Rome,Italy

STUDY OBJECTIVE: There exists conflicting evidence regarding the higher risk of hysterectomy among women of a lower educational and economic level. This study aims to assess whether in Italy socioeconomic level is related to hysterectomy undertaken for different medical reasons. DESIGN: An area based index was used to assign socieconomic status (SES; four levels defined) to 3141 women (aged 35 years or older) who underwent a hysterectomy in 1997 and were residing in Rome. Data were taken from hospital discharge records. Direct age standardised hospitalisation rates by SES level were calculated for overall hysterectomies and for those performed for either malignant or non-malignant causes. Statistical differences were detected using the ratios of standardised rates and the test for linear trend. MAIN RESULTS: The hysterectomy rate was 36.7 per 10 000 women aged 35 years or more. Hysterectomy for uterine leiomyoma accounted for 41% of all operations and was more frequent among women aged 35-49 years than for those aged 50 years or more (crude rates: 28.6 and 7.7 per 10 000, respectively). The risk of hysterectomy was 35% higher for the lowest SES group, compared with the highest group. No association was found between SES and hysterectomy rates for malignant causes, although less affluent women in age group 35-49 years had 87% higher risk of hysterectomy compared with most affluent women. The inverse association between SES and hysterectomy rates attributable to non-malignant causes was statistically significant for women aged 35-49 years but not for those aged 50 years or more. CONCLUSIONS: The inverse relation between hysterectomy and SES is largely attributable to benign disorders of the uterus, namely leiomyoma and prolapse. More affluent women may have a greater uptake of less invasive techniques for removing uterine leiomyoma compared with less affluent women, who are more likely to undergo unnecessary hysterectomies irrespective of their reproductive age.     

Nationwide rates of conversion from laparoscopic or vaginal hysterectomy to open abdominal hysterectomy in Germany

The aim of this study was to provide population-based German-wide hysterectomy rates based on the national hospitalization file and to estimate the rate of conversion from laparoscopical or vaginal hysterectomy to open abdominal hysterectomy. Nationwide population-based DRG (diagnosis related groups) data of the years 2005 and 2006 were used to calculate hysterectomy rates by indication group and type of surgical approach. Overall 305,015 hysterectomies were performed during the study period (4.5 out of 1,000 women aged 20 years or more). The hysterectomy rate for benign diseases of the genital tract among women aged 20 years or more (3.6 out of 1,000 women) is higher than in Sweden but lower than in the US or Australia. Only 6 and 5% of all hysterectomies were performed by laparoscopically assisted vaginal hysterectomy and laparoscopic hysterectomy, respectively. Twenty-six percent of hysterectomies for benign diseases among women aged 50 years or more included bilateral oophorectomy. 10% of laparoscopical hysterectomies and 1% of vaginal hysterectomies necessitated a conversion to an abdominal hysterectomy. For both types of hysterectomies, the conversion rates were highest for primary malignant genital tract cancer and other cancers compared to the other indication groups. Whereas the conversion rate for laparoscopical hysterectomies increased by age, this rate did not change by age for vaginal hysterectomies. Conversion from laparoscopically or vaginal hysterectomy to open abdominal hysterectomy is associated with the indication and type of hysterectomy started with and is considerably higher for laparoscopic than vaginal hysterectomies.     

Hysterectomy fractions in New South Wales, 1971–2006

Hysterectomy fractions by age group for particular periods are of interest for: estimating proper population denominators for calculation of disease and procedure rates affecting the cervix and uterus; estimating the target population for Pap test programs, and response rates; and as a way of displaying the cumulative consequences of hysterectomies in a population. Hysterectomy fractions for populations can be determined by direct inquiry via a representative sample survey, or, as in this study, from prior hysterectomy rates of the cohorts of women which compose each age bracket. Hysterectomy data 1979–93 were obtained from the hospital In-patients Statistics Collection (ISC) which covers both public and private hospitals in NSW. Annual population denominators of women were obtained from Census data. Data were modelled by Poisson regression, using five-year age group (15-≥85 years), annual period, and five-year birth cohort (APC model). Forward- and back-projection of the period effects were undertaken. The resultant NSW hysterectomy fractions by age and period are consistent with fractions obtained from modelled hysterectomy rates for Western Australia (1980–84), and fractions from national representative sample surveys (1989/90 and 1995) for younger women, but not for women aged >70 years in 1995, which revealed higher hysterectomy fractions than modelled hysterectomy data would suggest.
Hysterectomy fractions for NSW women by five-year age group for quinquennia centred on 1971 to 2006 are provided.     

The socioeconomic correlates of hysterectomies in the United States.

The purpose of this study was to examine the relationship between incidence of prior hysterectomy and education, income, and race. Data concerning previous hysterectomy and socioeconomic information were collected from 12,465 women 18 years or older as part of the Behavioral Risk Factor Surveillance System conducted in 16 states in 1988. The results indicate that women with less education and lower incomes were more likely to have had a hysterectomy. Race was not related to hysterectomy rate.     

Low socioeconomic status of the opposite sex is a risk factor for middle aged mortality

OBJECTIVES: To examine the relations between subjective social status, and objective socioeconomic status (as measured by income and education) in relation to male/female middle aged mortality rates across 150 sub-regions in Hungary. DESIGN: Cross sectional, ecological analyses. SETTING: 150 sub-regions of Hungary. PARTICIPANTS AND METHODS: 12,643 people were interviewed in the Hungaro-study 2002 survey, representing the Hungarian population according to sex, age, and sub-regions. Independent variables were subjective social status, personal income, and education. MAIN OUTCOME MEASURE: For ecological analyses, sex specific mortality rates were calculated for the middle aged population (45-64 years) in the 150 sub-regions of Hungary. RESULTS: In ecological analyses, education and subjective social status of women were more significantly associated with middle aged male mortality, than were male education, male subjective social status, and income. Among the socioeconomic factors female education was the most important protective factor of male mid-aged mortality. Subjective social status of the opposite sex was significantly associated with mid-aged mortality, more among men than among women. CONCLUSION: Pronounced sex interactions were found in the relations of education, subjective social status, and middle aged mortality rates. Men seem to be more vulnerable to the socioeconomic status of women than women to the effects of socioeconomic status of men. Subjective social status of women was an important predictor of mortality among middle aged men as was female education. The results suggest that improved socioeconomic status of women is protective for male health as well as for female health.     

Inpatient hospital care for lumbar intervertebral disc disorders in Finland in relation to education,occupational class,income, and employment

The object of the study was to describe socioeconomic and demographic determinants of inpatient hospital care for lumbar intervertebral disc disorders (LIDD) in Finland. Information from the 1996 Finnish Hospital Discharge Register was linked with the 1995 Population Census. Poisson regression analyses were made with the total and the gainfully employed workforce aged 20-64 y as reference. All 48 public and seven private acute care general hospitals treating LIDD patients in Finland. In the workforce, 4643 patients aged 20-64 y (3692 among the gainfully employed) were admitted to the hospital due to LIDD (ICD-10: M51.1-M51.9) in 1996. About one-half were treated surgically. The duration of unemployment in 1995 was inversely associated with hospitalisation for LIDD in 1996, allowing for age, sex, education and personal income (unemployed for 12 months vs 0 months: rate ratio 0.66; 95% CI 0.57-0.77). Among those employed for 12 months in 1995, the level of education was inversely associated with the hospital admission rate. The rate was also higher in manual occupations as compared with the upper white-collar employees. The associations were clearer among the medically than the surgically treated patients. Hospitalisation for back disorder was, however, less common in the lowest income group as compared with the highest (0.65; 0.57-0.77) allowing for education, occupational class, age and sex. Women were less often admitted to the hospital than men, allowing for the socioeconomic factors (0.83; 0.77-0.90). When indicated by education or occupation, low socioeconomic status was associated with a relatively high rate of inpatient hospital care for LIDD. When indicated by personal income, the situation was the reverse. Unemployment and female gender predicted a relatively low rate of hospitalisation.     

Prevalence of prior hysterectomy in the Seattle-Tacoma area

Hysterectomy is the most common major surgical procedure performed in the United States. The frequency of hysterectomy among women in the general population is of interest because it affects the population at risk for uterine diseases and because the procedure itself carries significant personal and socioeconomic consequences. We studied factors related to the occurrence of hysterectomy by interviewing a representative sample of women ages 35-74 (n= 1087) in two urban Washington counties during 1976-1977.

One-third of the women studied had had a hysterectomy. Later birth cohorts were at higher risk. The ageadjusted prevalence of prior hysterectomy was negatively associated with education and age at first childbirth; it was positively associated with parity, history of irregular menses, and history of a variety of other health conditions. Contrary to expectation, income was negatively associated with hysterectomy rates in one county and showed no association in the other. Part of the income effect was due to confounding by age at first childbirth, which was a surprisingly strong predictive factor.

We conclude that: 1) despite economic predictions based on the discretionary nature of the procedure, hysterectomies are not necessarily more common among high-income women; 2) age at first childbirth may be a more important risk factor for uterine disease than previously thought; and 3) estimates of hysterectomy frequency based on clinic populations may be misleading. (Am J Public Health 70:40-47, 1980.)

     

Factors associated with hysterectomy among older women from Latin America and the Caribbean

ABSTRACT

To identify factors associated with hysterectomy, data collected from 1999–2000 were assessed from seven cities of the Health, Well-Being and Aging in Latin America and the Caribbean Study on 6,549 women, aged 60 years and older. Hysterectomy prevalence ranged from 12.8% in Buenos Aires (Argentina) to 30.4% in Bridgetown (Barbados). The median age for having had a hysterectomy ranged from 45 to 50 years across the cities and was 47 years in the pooled sample. Ethnic differences in hysterectomy rates were partially explained by differences across cities. Factors significantly associated with lower odds for hysterectomy included older age, household crowding conditions, and having public/military or no health insurance, compared to having private health insurance. Women who had three or more children were less likely to have had a hysterectomy, a finding that differs from most previous studies. Socioeconomic position related to rates of hysterectomy in late life rather than hysterectomies earlier in life. However, the nature of these differences varied across birth cohorts. The findings suggested that adverse socioeconomic factors were most likely related to hysterectomy risk by affecting access to health care, whereas parity was most likely acting through an effect on decision-making processes.     

Trends in socioeconomic differences in sickness absence among Finnish municipal employees 1990-99

AIMS: This study examined the associations of key dimensions of socioeconomic status and long sickness absence spells as well as their changes over time from 1990 to 1999. METHODS: Municipal employees of the City of Helsinki, Finland, aged 25-59 were studied. The number of participants varied yearly from 24,029 women and 6,523 men to 27,861 women and 7,521 men. Socioeconomic status was assessed by education, occupational class, and individual income. The outcome was the number of over three days' sickness absence spells/100 person years, for which the employer requires medical certification. RESULTS: Low education, occupational class, and individual income were consistently associated with a 2-3 times higher sickness absence rates among both men and women. The age-adjusted sickness absence rates were relatively stable from 1990 to 1994 but increased from 1994 to 1999 among men and women. Socioeconomic differences in sickness absence rates tended to increase. CONCLUSIONS: The increase in the level of socioeconomic differences in sickness absence took place during a period of declining unemployment and staff increases at the City of Helsinki, which indicates that labour market conditions play a role in sickness absence.     

Early normal menstrual cycle pattern and the development of uterine leiomyomas

It is unclear if women who develop uterine leiomyomas have had menstrual regularity or irregularity in their reproductive life. This case-control study examines the recalled menstrual cycle patterns throughout the reproductive life among women requiring hysterectomy for myomas. One hundred twenty-two women with myomas and 244 age-matched healthy controls without myomas were enrolled in Japan. The incidence of normal menstrual cycle pattern in their teens among patients with myoma was significantly higher than that among healthy controls (p < 0.01). The subset results for parous women were the same as those for all subjects. The size of the uterus in myoma patients with teenage menstrual regularity was not larger than in those with teenage menstrual irregularity. Women who developed myomas later in life tended to have early normal menstrual cycle pattern. Early menstrual regularity may enhance leiomyoma growth in early reproductive life.     

What underlies the high alcohol related mortality of the disadvantaged: high morbidity or poor survival?

STUDY OBJECTIVE: To investigate whether the large socioeconomic differences in alcohol related mortality can be explained by differences in morbidity or differences in survival. DESIGN: Register linkage study. A nationwide hospital discharge register was linked to population censuses for socioeconomic data and to the cause of death register for mortality follow up. SETTING: Finland. PARTICIPANTS: Men and women aged 15 years and older discharged from hospitals with an alcohol related diagnosis in 1991-1996. MEASUREMENTS: Mortality hazard up to the end of 1997 by socioeconomic category was estimated with Cox's regression model. MAIN RESULTS: Socioeconomic differences in alcohol related hospitalisation rates were almost as large as those that have been observed for alcohol related mortality. For example, the rate ratio among male unspecialized workers for any alcohol related hospitalisations was 3.6 as compared with upper white collar workers; among women the rate ratio was 2.7. Depending on gender, age, hospitalisation diagnosis, and cause of death, survival after discharge either showed no socioeconomic differences or it was worse among better off groups. CONCLUSIONS: The study suggests that differences in survival after hospitalisation do not cause the high socioeconomic differences in alcohol related mortality.     

Cardiovascular risks and socioeconomic status: differences between men and women in Finland.

STUDY OBJECTIVE--The study aimed to assess the association of different indicators of socioeconomic status with levels of cardiovascular disease risk factors in men and women aged 25-64 years. DESIGN--This was a cross sectional survey, using a community based random sample. SETTING--The provinces of North Karelia and Kuopio in eastern Finland and the cities of Turku and Loimaa and surrounding communities in southwestern Finland in 1987. PARTICIPANTS--Altogether 2164 men and 2182 women aged 25-64 years took part. MEASUREMENTS AND MAIN RESULTS--Data were collected using self administered questionnaires and the measurement of height, body weight, and blood pressure and blood sampling for lipid determinations were done at the survey site. The risk of cardiovascular disease was determined by calculating a simple risk factor score based on the observed values of HDL and total cholesterol, leisure time, physical activity, blood pressure, medication for hypertension, body mass index, and smoking. Indicators of socioeconomic position used were years of education, family income, marital status, and the person's occupation. Lower levels of education, occupation, and income were all significantly associated with an unfavorable risk factor profile in men and women. Education and occupation showed the strongest associations with the risk factor score in both men and women. The results changed little when adjusting for income and marital status. Family income was more strongly associated with the risk factor score in women than men. When adjusting for occupation and education, income was no longer significantly associated with the risk factor score in men. Marital status was not significantly associated with the risk factor score in either sex. CONCLUSIONS--Using the strength of the association with the cardiovascular risk factor score as the criterion for a good socioeconomic indicator, the present study suggests that education and occupation may be equally good indicators in both men and women. Family income may have some additional importance, especially in women.     

Trends of socioeconomic differences in daily vegetable consumption, 1979-2002

BACKGROUND: Studies from different time periods have shown that consumption of vegetables is more common in higher socioeconomic groups and among women. However, there are only few studies of changes of socioeconomic differences in vegetable consumption over time. Our aim was to determine whether socioeconomic differences, measured by educational level and household income, in daily vegetable consumption have increased, decreased or been stable over the last two decades among Finnish men and women. METHODS: Data on daily consumption of fresh vegetables were derived from repeated annual cross-sectional surveys performed among representative samples of Finnish working aged (15-64 years) population. Data from the years 1979-2002 were linked with data on education and household income from Statistics Finland. Those under 25 years and all students were excluded, giving a total of 69 383 respondents. The main analyses were conducted with logistic regression. RESULTS: Daily consumption of fresh vegetables became overall more prevalent during the study period. Daily consumption of fresh vegetables was more common among those with higher education and higher income during the whole study period. Both educational level and household income differences in daily vegetable consumption slightly narrowed since 1979 among men and women. CONCLUSIONS: Women with high socioeconomic position have been initial trend setters, but the prevalence of daily consumers of vegetables in these groups has not increased since the early 1990s. The prevalence of daily consumption of fresh vegetables has increased more in lower educational and income groups during the 1980s and 1990s along with narrowing socioeconomic differences.     

Socioeconomic disparities in breast cancer screening among US women: trends from 2000 to 2005.

OBJECTIVES: This study describes trends in the socioeconomic disparities in breast cancer screening among US women aged 40 or over, from 2000 to 2005. We assessed 1) the disparities in each socioeconomic dimension; 2) the changes in screening mammography rates over time according to income, education, and race; and 3) the sizes and trends of the disparities over time. METHODS: Using data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2000 to 2005, we calculated the age-adjusted screening rate according to relative household income, education level, health insurance, and race. Odds ratios and the relative inequality index (RII) were also calculated, controlling for age. RESULTS: Women in their 40s and those with lower relative incomes were less likely to undergo screening mammography. The disparity based on relative income was greater than that based on education or race (the RII among low-income women across the survey years was 3.00 to 3.48). The overall participation rate and absolute differences among socioeconomic groups changed little or decreased slightly across the survey years. However, the degree of each socioeconomic disparity and the relative inequality among socioeconomic positions remained quite consistent. CONCLUSIONS: These findings suggest that the trend of the disparity in breast cancer screening varied by socioeconomic dimension. Continued differences in breast cancer screening rates related to income level should be considered in future efforts to decrease the disparities in breast cancer among socioeconomic groups. More focused interventions, as well as the monitoring of trends in cancer screening participation by income and education, are needed in different social settings.     

Endometrial cancer: socioeconomic status and racial/ethnic differences in stage at diagnosis, treatment, and survival

OBJECTIVE: We evaluated the association between socioeconomic status and racial/ ethnic differences in endometrial cancer stage at diagnosis, treatment, and survival. METHODS: We conducted a population-based study among 3656 women. RESULTS: Multivariate analyses showed that either race/ethnicity or income, but not both, was associated with advanced-stage disease. Age, stage at diagnosis, and income were independent predictors of hysterectomy. African American ethnicity, increased age, aggressive histology, poor tumor grade, and advanced-stage disease were associated with increased risk for death; higher income and hysterectomy were associated with decreased risk for death. CONCLUSIONS: Lower income was associated with advanced-stage disease, lower likelihood of receiving a hysterectomy, and lower rates of survival. Earlier diagnosis and removal of barriers to optimal treatment among lower-socioeconomic status women will diminish racial/ethnic differences in endometrial cancer survival.     

The role of socioeconomic indicators on non-alcohol and alcohol-associated suicide mortality among women in Finland. A register-based follow-up study of 12 million person-years

This study was to analyse the effects and interrelationships of three socioeconomic indicators – education, occupation-based social class and income – on non-alcohol and alcohol-associated suicide mortality among women in Finland. The register data used comprised the 1990 census records linked to the death register for the years 1991–2001 for women who were 25–64 years old in 1990. Adjusted relative mortality rates and the relative index of inequality (RII) were estimated using Poisson regression. The study population experienced 1926 suicides, of which 563 (29%) had alcohol intoxication as a contributory cause. The age-adjusted effects of education on non-alcohol associated suicide were modest, while social class and income related inversely and strongly. The effect of social class was partly mediated by income, and social class explained income differences to some extent. The associations between these socioeconomic indicators and alcohol-associated suicide were stronger, and following adjustment for each other large effects were left for education, social class and income. Further adjustment for living arrangements had little effect on socioeconomic differences in both types of suicide, but practically all of the effects of income and some of education and social class were mediated by employment status. In conclusion, current material factors are hardly the main underlying drivers of socioeconomic differences in suicide among Finnish women. Low social class proved to be an important determinant of suicide risk, but the strong independent effect of education on alcohol-associated suicide indicates that the roots of these differences are probably established in early adulthood when educational qualifications are obtained and health-behavioural patterns set.     

Relation of socioeconomic position to the case fatality, prognosis and treatment of myocardial infarction events; the FINMONICA MI Register Study

OBJECTIVE: To examine socioeconomic differences in case fatality and prognosis of myocardial infarction (MI) events, and to estimate the contributions of incidence and case fatality to socioeconomic differences in coronary heart disease (CHD) mortality. DESIGN: A population-based MI register study. METHODS: The FINMONICA MI Register recorded all MI events among persons aged 35-64 years in three areas of Finland during 1983-1992. A record linkage of the MI Register data with the files of Statistics Finland was performed to obtain information on socioeconomic indicators for each individual registered. First MI events (n=8427) were included in the analyses. MAIN RESULTS: The adjusted risk ratio of prehospital coronary death was 2.11 (95% CI 1.82, 2.46) among men and 1.68 (1.14, 2.48) among women with low income compared with those with high income. Even among persons hospitalised alive the risk of death during the next 12 months was markedly higher in the low income group than in the high income group. Case fatality explained 51% of the CHD mortality difference between the low and the high income groups among men and 38% among women. Incidence contributed 49% and 62%, respectively. CONCLUSIONS: Considerable socioeconomic differences were observed in the case fatality of first coronary events both before hospitalisation and among patients hospitalised alive. Case fatality explained a half of the CHD mortality difference between the low and the high income groups among men and more than a third among women.