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BackgroundDespite universal healthcare, socioeconomic differences in healthcare utilization (HCU) persist in modern welfare states. However, little is known of how HCU inequalities has developed over time. The aim of this study is to assess time trends of differences in utilization of primary and specialized care for the lowest (Q1) and highest (Q5) income quantiles and compare these to mortality.Methods and findingsUsing a repeated cross-sectional register-based study design, data on utilization of (i) primary; (ii) specialized outpatient; and (iii) inpatient care, as well as (iv) cause of death, were linked to family income and sociodemographic control variables (for instance, country of origin and marital status). The study sample comprised all individuals 16 years or older residing in Sweden any year during the study period and ranged from 7.1 million in year 2004 to 8.0 million year 2017. HCU and mortality for all disease as well as for the 5 disease groups causing most deaths were compared for the Q1 and Q5 using logistic regression, adjusting for sex, age, marital status, and birth country. The primary outcome measures were adjusted odds ratios (ORs), and regression coefficients of annual changes in these ORs log-transformed. Additionally, we conducted negative binominal regression to calculate adjusted rate ratios (RRs) comparing Q1 and Q5 with regard to number of disease specific healthcare encounters ≤5 years prior to death. In 2017, for all diseases combined, Q1 utilized marginally more primary and specialized outpatient care than Q5 (OR 1.07, 95% CI [1.07, 1.08]; p < 0.001, and OR 1.04, 95% CI [1.04, 1.05]; p < 0.001, respectively), and considerably more inpatient care (OR 1.44, 95% CI [1.43, 1.45]; p < 0.001). The largest relative inequality was observed for mortality (OR 1.78, 95% CI [1.74, 1.82]; p < 0.001). This pattern was broadly reproduced for each of the 5 disease groups. Time trends in HCU inequality varied by level of care. Each year, Q1 (versus Q5) used more inpatient care and suffered increasing mortality rates. However, utilization of primary and specialized outpatient care increased more among Q5 than in Q1. Finally, group differences in number of healthcare encounters ≤5 years prior to death demonstrated a similar pattern. For each disease group, primary and outpatient care encounters were fewer in Q1 than in Q5, while inpatient encounters were similar or higher in Q1. A main limitation of this study is the absence of data on self-reported need for care, which impedes quantifications of HCU inequalities each year.ConclusionsIncome-related differences in the utilization of primary and specialized outpatient care were considerably smaller than for mortality, and this discrepancy widened with time. Facilitating motivated use of primary and outpatient care among low-income groups could help mitigate the growing health inequalities.

Lack of skilled human resources in primary care remains a major concern for policymakers in low- and middle-income countries. There is little evidence supporting the impact of residency training in family medicine in the quality of care, and it perpetuates misconceptions among policymakers that the provision of primary care can be easily done by any physician without special training. This article compares the risk of patients being hospitalized due to Ambulatory care sensitive conditions and the odds of having follow-up visits in primary care after hospital discharge, according to the type of their medical provider: (1) Generalists (reference), (2) Family physicians; and, (3) patients with no consultations prior to the event. Multilevel multivariate binomial regression models estimated the relative risks of a patient being hospitalized in a given month and the relative risks for the occurrence of a follow-up visit in primary care in a retrospective cohort of 636.640 patients between January 2013 and July 2018 in Rio de Janeiro. For all 14 conditions, there was a higher risk of hospitalization when patients had no consultation in primary care prior to the event. Except for Ear, Nose and Throat infections, patients seen by family physicians had a lower risk of being hospitalized, compared to patients seen by Generalists. Follow-up visits were more likely to happen among patients treated by family physicians for almost every condition analyzed. With two years of training in family medicine, Family physicians can reduce the risk of their patients being hospitalized and increase the likelihood of those patients having a follow-up consultation in primary care. Investments in residency training in family medicine should be made to fix the shortage of skilled physicians in primary care, reduce hospitalizations and improve quality and continuity of care.

OBJECTIVES:Comorbidity is prevalent in older working ages and might affect employment exits. This study aimed to 1) assess the associations between comorbidity and different employment exit routes, and 2) examine such associations by gender. METHODS:We used data from employed adults aged 50-62 in the Stockholm Public Health Survey 2002 and 2006, linked to longitudinal administrative income records (N = 10,416). The morbidity measure combined Limiting Longstanding Illness and Common Mental Disorder-captured by the General Health Questionnaire-12 (≥4)-into a categorical variable: 1) No Limiting Longstanding Illness, no Common Mental Disorder, 2) Limiting Longstanding Illness only, 3) Common Mental Disorder only, and 4) comorbid Limiting Longstanding Illness+Common Mental Disorder. Employment status was followed up until 2010, treating early retirement, disability pension and unemployment as employment exits. Competing risk regression analysed the associations between morbidity and employment exit routes, stratifying by gender. RESULTS:Compared to No Limiting Longstanding Illness, no Common Mental Disorder, comorbid Limiting Longstanding Illness+Common Mental Disorder was associated with early retirement in men (subdistribution hazard ratio = 1.73, 95% confidence intervals: 1.08-2.76), but not in women. For men and women, strong associations for disability pension were observed with Limiting Longstanding Illness only (subdistribution hazard ratio = 11.43, 95% confidence intervals: 9.40-13.89) and Limiting Longstanding Illness+Common Mental Disorder (subdistribution hazard ratio = 14.25, 95% confidence intervals: 10.91-18.61), and to a lesser extent Common Mental Disorder only (subdistribution hazard ratio = 2.00, 95% confidence intervals: 1.31-3.05). Women were more likely to exit through disability pension than men (subdistribution hazard ratio = 1.96, 95% confidence intervals: 1.60-2.39). Common Mental Disorder only was the only morbidity category associated with unemployment (subdistribution hazard ratio = 1.70, 95% confidence intervals: 1.36-2.15). CONCLUSIONS:Strong associations were observed between specific morbidity categories with different employment exit routes, which differed by gender. Initiatives to extend working lives should consider older workers' varied health needs to prevent inequalities in older age.

BACKGROUND:Keeping older workers in employment is critical for societies facing the challenge of an ageing population. This study examined the association between types of health conditions and differentials in the probability of employment by level of education among men and women between 60-69 years of age in Canada, Denmark, Sweden and England. METHODS:Data were drawn from the Canadian Community Health Survey, Survey of Health, Ageing and Retirement in Europe and English Longitudinal Study of Ageing. We combined country data, applied logistic regression, adjusted for educational level, and stratified the analysis by sex to calculate the odds ratio (OR) of employment (>15 hours work per week) for persons with physical health conditions, mental health conditions (depression) and physical-mental health comorbidity. RESULTS:The odds of employment among men and women with physical-mental health comorbidity were lower compared to those with no/other conditions (men: OR 0.32, 95% CI: 0.25-0.42, women: OR 0.38 95% CI: 0.30-0.48). Women with low education had lower odds of employment compared to their counterparts with high education (OR 0.66, 95% CI: 0.57-0.76). The odds of employment at older ages was lower in Canada, Denmark and England compared with Sweden (e.g. English men: OR 0.48 95% CI 0.40-0.58; English women OR 0.33 95% CI 0.27-0.41). CONCLUSIONS:The odds of employment beyond age 60 is lower for groups with low education, particularly women, and those with physical-mental health co-morbidities. As such, policies to extend working lives should not be 'one size fits all' but instead consider subgroups, in particular, these groups that we have shown to be most vulnerable on the labour market.

BackgroundRestrictions in the eligibility requirements for disability benefits have been introduced in many countries, on the assumption that this will increase work incentives for people with chronic illness and disabilities. Evidence to support this assumption is unclear, but there is a danger that removal of social protection without increased employment would increase the risk of poverty among disabled people. This paper presents a systematic review of the evidence on the employment effects of changes to eligibility criteria across OECD countries.MethodsSystematic review of all empirical studies from OECD countries from 1990 to June 2018 investigating the effect of changes in eligibility requirements and income replacement level of disability benefits on the employment of disabled people. Studies were narratively synthesised, and meta-analysis was performed using meta-regression on all separate results. The systematic review protocol was registered with the Prospective Register for Systematic Reviews (Registration code: PROSPERO 2018 CRD42018103930).ResultsSeventeen studies met inclusion criteria from seven countries. Eight investigated an expansion of eligibility criteria and nine a restriction. There were 36 separate results included from the 17 studies. Fourteen examined an expansion of eligibility; six found significantly reduced employment, eight no significant effect and one increased employment. Twenty-two results examined a restriction in eligibility for benefits; three found significantly increased employment, 18 no significant effect and one reduced employment. Meta-regression of all studies produced a relative risk of employment of 1.06 (95% CI 0.999 to 1.014; I2 77%).ConclusionsThere was no firm evidence that changes in eligibility affected employment of disabled people. Restricting eligibility therefore has the potential to lead to a growing number of people out of employment with health problems who are not eligible for adequate social protection, increasing their risk of poverty. Policymakers and researchers need to address the lack of robust evidence for assessing the employment impact of these types of welfare reforms as well as the potential wider poverty impacts.