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.     

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.     

Are there socioeconomic differences in myocardial infarction event rates and fatality among patients with angina pectoris?

BACKGROUND: Systematic socioeconomic differences in mortality have been reported among myocardial infarction (MI) patients in many countries, including Finland. The findings have been similar irrespective of country, study period, age group, or length of follow up, but few studies have examined the disparities among other groups of coronary patients. This study examined whether similar socioeconomic differences in outcomes exist among patients with angina pectoris (AP). METHODS: The data were based on individual register linkages among a population based 40-79 year-old cohort of 61,350 patients with incident AP or MI during 1995-1998 in Finland. Two year coronary heart disease mortality and one year MI incidence and its 28 day case fatality was studied among AP patients using Cox's and logistic regression analysis, and the results compared with those of the MI patient group. RESULTS: A clear socioeconomic pattern was found in two year coronary heart disease (CHD) mortality: the lower the socioeconomic group the higher the mortality risk. The socioeconomic patterning of mortality was similar to that found among MI patients. Controlling for comorbidity or disease severity did not change the results. Among AP patients a similar pattern was also found in MI incidence during the follow up, but no systematic socioeconomic differences were detected in its 28 day case fatality. CONCLUSIONS: Socioeconomic differences in CHD outcomes also exist among angina patients. These results suggest that targeted measures of secondary prevention are needed among CHD patients with lower socioeconomic status to reduce socioeconomic disparities in fatal and non-fatal coronary events.     

The validity of the routine mortality statistics on coronary heart disease in Finland: comparison with the FINMONICA MI register data for the years 1983-1992. Finnish multinational MONItoring of trends and determinants in CArdiovascular disease

We compared the diagnoses obtained from the routine mortality statistics with the standardized World Health Organization (WHO) MONICA (multinational MONItoring of trends and determinants in CArdiovascular disease) classification in suspect coronary heart disease (CHD) deaths registered in the FINMONICA myocardial infarction (MI) register during 1983-1992. All CHD deaths from routine mortality statistics (International Classification of Diseases codes 410-414) were registered in the MI register. Of the CHD deaths in routine mortality statistics 1.7% in men and 4.8% in women did not fulfill the MONICA criteria for CHD death (P<0.001 for the difference between the sexes). In men 4.7% and in women 7.3% (P=0.004) of the deaths registered in the MI Register and classified as CHD deaths by MONICA criteria had another underlying cause of death than CHD in routine mortality statistics; this proportion increased over time in both sexes (P=0.002 in men and P=0.77 in women). The CHD mortality trends obtained separately from the routine mortality statistics and from the FINMONICA MI Register were very similar. In conclusion, the high CHD mortality in Finland reported by the routine mortality statistics is real. It is possible that some CHD deaths have escaped registration, but the decline seen in the CHD mortality is also real.     

Return to work after first myocardial infarction in 1991-1996 in Finland

BACKGROUND: A substantial number of myocardial infarctions (MI) occur at working age. It is, however, insufficiently well known how many of these patients return to work after their MI. METHODS: Sources of information were the Hospital Discharge Register, the Causes of Death Register and the registers for social security benefits. Availability for the labour market was used as the return to work criterion. Altogether 10,244 persons (8,733 men, 1,511 women) aged 35-59 years had their first MI or coronary death during 1991-1994 in Finland. Persons who survived for 28 days and were not on pension at the time of MI were included in a two-year follow-up. RESULTS: Twenty-nine per cent of patients were already pensioned at the time of their first MI. Of the patients not pensioned at the time of their MI, 4,929 were alive two years after the event. Of them, 38% of men and 40% of women received disability pension, 3% of both genders were on sick leave and 1% of both genders were on unemployment pension. The remainder, 58% of men and 56% of women, did not receive any of these benefits, thus, being available to the labour force. CONCLUSIONS: Nearly one-third of persons having their first MI at working age were already out of the labour force at the time of their MI. Of those who were not pensioned and who survived the event, slightly more than half were available to the labour market two years later.     

Health surveillance for asthma in the US Navy: experience of 9,185,484 person-years

PURPOSE: To measure trends and demographic risk factors for hospitalization for asthma. METHODS: Time trends and demographic risk factors, for hospitalized asthma (1CD-9-CM Code 493) were analyzed by measuring age-specific and age-adjusted first hospitalization rates in a defined population of active-duty enlisted members of the US Navy worldwide during 1980-1999, consisting of 9,185,484 person-years. RESULTS: There were 3911 patients first hospitalized for asthma, including 2916 men and 995 women. The age-adjusted incidence rate of first hospitalization for asthma was three times higher in women than men, 110 per 100,000 person-years (95% confidence interval [CI], 104-117), compared with 35 per 100,000 person-years (95% CI, 33-37), respectively (p < 0.0001). The rate in black women was twice as high as in white women, 186 per 100,000 person-years, compared with 99 per 100,000 person-years, respectively (p < 0.001). The rate in black men was higher than in white men, 45 per 100,000, compared with 34 per 100,000 (p < 0.001). Age-adjusted rates in women doubled from 73 per 100,000 in 1980-1983 to 159 in 1997-1999 (p for trend < 0.01), while those in men remained stable. CONCLUSIONS: Age-adjusted incidence rates of first hospitalization for asthma were three times as high in women as in men, and doubled during the period between 1980 and 1999. The rates in black women were twice as high as in white women. The reasons are unknown.     

Regional Variability in Population Acute Myocardial Infarction Cumulative Incidence and Mortality Rates in Spain 1997 and 1998

BACKGROUND: Myocardial infarction (MI) incidence and mortality display a high geographic variation. AIMS: The objective of the present study was to analyze MI mortality, cumulative incidence rate variability in seven regions of Spain from 1997 to 1998. METHODS AND RESULTS: Standardized methods were used to identify, find, register, and classify MI cases that were classified as definite, possible, insufficient-data MI, and non-MI. The total population of the seven monitored regions was 7,364,682 inhabitants. Of the 11,256 cases fulfilling eligibility criteria to investigate, 10,660 were selected to calculate MI rates: 6554 (61.5%) non-fatal definite MI, 1179 (11.1%) fatal definite MI, 1859 (17.4%) fatal possible MI, 1068 (10.0%) fatal cases with insufficient data. The IBERICA 25-74 years age-standardized cumulative incidence rates for men and women, were 207 (range: 175-252) and 45 (range: 36-65) per 100,000, respectively. The age-standardized mortality rates for men and women, were 73 (range: 62-94) and 20 (range: 13-29) per 100,000, respectively. Age-standardized case-fatality was 31.4 and 24.2% in men aged 25-74 and 35-64 years, respectively, and 32.7 and 27.0%, respectively, in women. CONCLUSIONS: MI cumulative incidence and mortality rates are low compared with other industrialized countries but, vary considerably among regions in a Mediterranean country like Spain.     

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.     

Incidence of cancer in Navarra. 1995-96

The present paper studies the results of the incidence of cancer in Navarra during 1995-96. The collection of data for the years 1995-1996 was carried out in an active form in the information sources of the register. The procedures for collection, control of duplicates and processing of previous years was maintained. Both the quality indicators and the calculations of the different rates were obtained following the recommendations proposed by the International Agency for Research on Cancer (IARC). In 1995-96, 5,667 incident cases of malign tumours were registered in Navarra; 58% occurred in men. Excluding non-melanoma skin cancer, the gross rate of incidence was 513.7 in men and 344.9 in women, the rate adjusted to the world population was 301 per 100,000 for men and 192 per 100,000 for women. Fifty six per cent of all the cases of cancer diagnosed during 1995-1996 in men occurred in the locations of lung, prostate, colon, stomach and bladder. In women the locations of breast, colon, body of the uterus, stomach and rectum represented 51% of total cases.     

Gender disparities in the quality of cardiovascular disease care in private managed care plans.

BACKGROUND: Studies have shown that women with cardiovascular disease (CVD) are screened and treated less aggressively than men and are less likely to undergo cardiac procedures. Research in this area has primarily focused on the acute setting, and there are limited data on the ambulatory care setting, particularly among the commercially insured. To that end, the objective of this study is to determine if gender disparities in the quality of CVD care exist in commercial managed care populations. METHODS: Using a national sample of commercial health plans, we analyzed member-level data for 7 CVD quality indicators from the Healthcare Effectiveness Data and Information Set (HEDIS) collected in 2005. We used hierarchical generalized linear models to estimate these HEDIS measures as a function of gender, controlling for race/ethnicity, socioeconomic status, age, and plans' clustering effects. RESULTS: Results showed that women were less likely than men to have low-density lipoprotein (LDL) cholesterol controlled at <100 mg/dL in those who have diabetes (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.76-0.86) or a history of CVD (OR, 0.72; CI 95%, 0.64-0.82). The difference between men and women in meeting the LDL control measures was 5.74% among those with diabetes (44.3% vs. 38.5%) and 8.53% among those with a history of CVD (55.1% vs. 46.6%). However, women achieved higher performance than men in controlling blood pressure (OR, 1.12; 95% CI, 1.02-1.21), where the rate of women meeting this quality indicator exceeded that of men by 1.94% (70.8% for women vs. 68.9% for men). CONCLUSIONS: Gender disparities in the management and outcomes of CVD exist among patients in commercial managed care plans despite similar access to care. Poor performance in LDL control was seen in both men and women, with a lower rate of control in women suggesting the possibility of less intensive cholesterol treatment in women. The differences in patterns of care demonstrate the need for interventions tailored to address gender disparities.     

First results from the MONICA stroke register in Heidelberg

The Stroke Register was established in 1984 in Heidelberg, as a part of the MONICA Project, covering the same population (approximately 601,000) as the Acute Myocardial Infarction Register. In the present analysis, the data for men and women (aged 25-64) for 1985 and 1986 are presented. During the two years, 303 men and 143 women were registered. The overall age-standardized attack rate was 127.2/100,000 for men and 52.8/100,000 for women, and the age-standardized incidence was 97.4/100,000 in men and 42.9/100,000 in women. The proportion of first stroke was 76.5% in men and 81% in women. The 28-days mortality was 12% for men and 19% for women. Hypertension, diabetes mellitus, smoking and heart disease (coronary heart disease, rhythm disturbances) were identified as risk factors for stroke. Among the registered victims of stroke, 61% of the men and 67% of the women had a history of hypertension. In men, a high prevalence of smokers, 54% was found (33.9% in the total population in the same age range). In women, the prevalence of smokers is nearly the same as in the total population. Diabetes mellitus was present in 23% of men and in 40% of women, and hyperlipidaemia in 30% of men and in 18% of women.     

Short- and long-term mortality after acute myocardial infarction: comparison of patients with and without diabetes mellitus

Aims To compare short- and long-term mortality after a first acute myocardial infarction (AMI) in patients with and without diabetes mellitus. Methods and results A nationwide cohort of 2,018 diabetic and 19,547 nondiabetic patients with a first hospitalized AMI in 1995 was identified through linkage of the national hospital discharge register and the population register. Follow-up for mortality lasted until the end of 2000. At 28 days and 5 years respectively, absolute mortality risks were 18 and 53% in diabetic men, 12 and 31% in nondiabetic men, 22 and 58% in diabetic women, and 19 and 42% in nondiabetic women. Crude mortality was significantly higher in diabetic patients than in nondiabetic patients in both men (28-day hazard ratio (HR) 1.55; 95% confidence interval (CI) 1.32–1.81, 5-year HR 2.01; 95% CI 1.84–2.21) and women (28-day HR 1.19; 95% CI 1.03–1.37, 5-year HR 1.53; 95% CI 1.40–1.67). After multivariate adjustment, risk differences became nonsignificant at 28 days, but diabetes was still associated with a significantly higher long-term mortality in both men (28-day HR 1.16; 95% CI 0.99–1.36, 5-year HR 1.49; 95% CI 1.36–1.64) and women (28-day HR 1.12; 95% CI 0.97–1.28, 5-year HR 1.39; 95% CI 1.27–1.52). The interaction between diabetes mellitus and gender did not reach significance in the analyses. Conclusion Our findings in an unselected cohort covering a complete nation show a significantly higher long-term mortality after a first acute myocardial infarction in diabetic patients. Yet, short-term mortality is not significantly higher in diabetic patients. Risks appear to be equally elevated in men and women.     

Social inequalities and outcomes in type 2 diabetes in the German region of Augsburg. A cross-sectional survey.

Summary Objectives: To assess the association of socioeconomic position with health (care) outcomes in type 2 diabetes with a particular focus on glycaemic control. Methods: A cross-sectional survey in the region of Augsburg (Germany) on 373 men and women with type 2 diabetes, drawn from representative MONICA surveys and the myocardial infarct register. Analysis of association of socioeconomic position with HbA1c levels, cardiovascular risk factors and long-term macro- and microvascular diabetes complications using logistic regression models. Results: Glycaemic control, measured by HbA1c levels, is strongly associated with indicators of socioeconomic position favouring the better off. Comparison of the lowest with the highest socioeconomic group showed an odds ratio of 2.49 (95% CI: 1.22–5.07) for the MI register subgroup and 1.80 (95% CI: 0.80–4.06) for the survey subgroup for failure to achieve the recommended HbA1c target. This association could not be accounted for by differences across social groups in age, sex, diabetes duration, obesity, or physical activity. Conclusions: Social inequalities in glycaemic control do exist. This finding may indicate a level of diabetes care that is inappropriate to the need of socially disadvantaged groups. Submitted: 22 June 2005; Revised: 15 September 2006; Accepted: 13 March 2007     

Obesity and education: recent trends and disparities among 65- to 84-year-old men and women in Finland

OBJECTIVES: The purpose of this study was to analyze trends and disparities in obesity by education among Finnish men and women aged 65-84 years from 1993 to 2003. METHOD.: Data were derived from nationally representative monitoring surveys conducted biennially from 1993 to 2003 by the National Public Health Institute (KTL). In total, 5740 men and 5746 women were included in the study (response rate 80%). Obesity was set as body mass index (BMI) >or=30, based on self-reported measurements. Age adjusted trends were examined by education and gender. A logistic regression model was used to study educational disparities in obesity. RESULTS: Obesity trends were similar among men and women. The prevalence of obesity increased in both educational groups over the ten-year period. Throughout the period, those with lower education had higher risk of obesity, and educational disparities persisted at about the same level. CONCLUSIONS: Obesity is increasing among older people. Information on continuing socioeconomic disparities in obesity is important for those targeting health promotion activities.     

Does the patient's sex influence cardiovascular outcome after acute myocardial infarction?

OBJECTIVES: To determine whether outcome differences based on the patient's sex occur after myocardial infarction (MI) at a large private hospital. STUDY DESIGN: We conducted a large cohort study. POPULATION: Inclusion required hospital admission between January 1, 1998, and June 30, 1999, and a diagnosis of acute MI or subendocardial infarction. The number of patients included in the study was 1669. Data were collected at discharge on age, sex, race, health insurance, hypercholesterolemia, diabetes, smoking, hypertension, and the extent of coronary artery disease. OUTCOMES MEASURED: The 8 outcomes analyzed were angiogram, angioplasty, stent placement, coronary artery bypass grafting (CABG), mortality, time in the intensive care unit, total length of stay, and combined catheterization procedures. RESULTS: After adjusting for 7 confounding variables, we found no significant differences between men and women for mortality, ICU time, total hospital time, stent placement, angiogram, angioplasty, or combined catheterization procedures. Men had significantly more CABG (relative risk [RR] 1.96, P <.01). Among patients who underwent CABG (N = 204), men had significantly more 3-vessel coronary disease (RR 1.44, P <.01) and left main coronary artery disease greater than 50% (RR 1.58, P <.01). Once we had controlled for the extent of coronary artery disease, we found no difference between the sexes for CABG. CONCLUSIONS: During hospitalization after an MI, most cardiovascular outcomes and process measures are the same for men and women. The greater frequency of CABG in men than in women is explained by men's greater frequency of 3-vessel and advanced left-main coronary disease.     

Relative weight and income at different levels of socioeconomic status

OBJECTIVES: We examined the association of relative weight with individual income at different levels of socioeconomic status among gainfully employed Finnish women and men. METHODS: We used a population-based survey including 2068 women and 2314 men with linked income data from a taxation register. Regression analysis was used to calculate mean income levels within educational and occupational groups. RESULTS: Compared with their normal-weight counterparts, obese women with higher education or in upper white-collar positions had significantly lower income; a smaller income disadvantage was seen in overweight women with secondary education and in manual workers. Excess body weight was not associated with income disadvantages in men. CONCLUSIONS: Obesity is associated with a clear income disadvantage, particularly among women with higher socioeconomic status.     

Incidence of cancer in Navarra

The data on the incidence of cancer in Navarra for the two year period 1993-94 is set out by age groups and sex, with the aim of making available the most recent information contained in the Navarra Cancer Register. The collection of data for the years 1993-94 was carried out in an active manner in the information sources of the register. The procedures of previous years regarding collection, control of duplicates and processing were maintained. Both the quality indicators and the calculations of the different rates were obtained following the recommendations proposed by the International Agency for Research on Cancer (IARC). In the 1993-1994 period, 5.186 incident cases of malign tumours were registered in Navarra. Some 59% occurred in men. Excluding nonmelanoma skin cancer, the crude rate of incidence was 475 in men and 319 in women; the rate adjusted to the world population was 297 per 100,000 for men and 186 per 100,000 for women. If nonmelanoma skin cancer is excluded, 55% of all of the cancer cases diagnosed during 1993-1994 in men were located in the lung, prostate, bladder, colon and stomach. In women they were located in the breast, body of the uterus, colon, lymphoid tissue and stomach, representing 56% of the total cases.     

Epidemiology of adulthood injuries: a quickly changing injury profile in Finland

Although developed societies have undergone many profound changes during recent decades, including urbanization, increased traffic and aging of the populations, epidemiologic information on secular trends in profiles of injuries is limited. We investigated such trends in Finland by selecting from the National Hospital Discharge Register all Finns aged 15 years or more who required hospital treatment because of an unintentional injury during 1971-1995. The injury incidences were expressed as the number of patients per 100,000 individuals per year. In Finnish men, road traffic accidents and falls, the two leading causes of injury, produced equal numbers of injuries in 1971 (4935 and 4957), but thereafter the role of the traffic accidents gradually decreased (3512 injuries with unadjusted and age-adjusted incidences of 177 and 183 in 1995) and that of falls clearly increased (13,218 injuries with unadjusted and age-adjusted incidences of 664 and 635 in 1995). Changes in the other injury categories of men were less drastic. In Finnish women, falling was the most common cause of injury in 1971 (5051 injuries), after which its role increased sharply, to 17,250 injuries in 1995 (unadjusted and age-adjusted incidences of 804 and 698, respectively). In 1971, road traffic produced 2369 injuries in women, after which this number somewhat decreased (2160 injuries with unadjusted and age-adjusted incidences of 101 and 101 in 1995). The role of all the other injury categories was small in Finnish women during 1971-1995. We conclude that a quick change in the overall profile of injuries occurred in Finland in 1971-1995, a change in which falls replaced road traffic accidents as the major cause of a serious injury. This epidemiologic change will give a new challenge for injury prevention in the new millennium.     

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.