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Source publication
Objective
To assess socioeconomic differences between patients registered with private and public primary healthcare centres.
Design
Population-based cross-sectional study controlling for municipality and household.
Setting
Swedish population-based socioeconomic data collected from Statistics Sweden linked with individual registration data from a...
Contexts in source publication
Context 1
... individuals living in municipalities without alternative PHCCs to choose from were excluded (samples 1 and 2), the results show the same trends but with a slightly higher magnitude. To further assess the robustness of the results, a density plot was generated (see figure 2). ...
Context 2
... density plot in figure 2 reveals that the likelihood of registering with a private PHCC is consistently based on disposable income, that is, up until a certain level of income an individual is more likely to register with a public PHCC. After that level, individuals are more likely to register with a private PHCC. ...
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Background
The Swedish healthcare system aims to provide equal access to care to all residents yet evidence suggests that patients with low socioeconomic status are less likely to receive new drugs. Associations between sociodemographics and prescription of non-vitamin K antagonist oral anticoagulants (NOACs) as an alternative to warfarin in Sweden...
Citations
... As summarized in a couple of reviews (Burstrom et al., 2017;Fredriksson and Isaksson, 2022), several signs of inequitable consequences have been reported, such as those relating to the location of new private health care centers (Isaksson et al., 2016), composition of patients (Isaksson et al., 2018), and PHC utilization (Beckman and Anell, 2013). Evaluations of PHC-related population impact of the reform are so far sparse, with only two recent studies, reporting no effects on avoidable hospitalizations (Dietrichson et al., 2020;Mosquera et al., 2021), but with worse outcomes in regions with long-term dominance of private providers (Mosquera et al., 2021). ...
... An increasing number of private health providers and the free right to establish care centers in any location has, in recent years, reduced the number of child and maternal care units in poorer areas where the need is greater [24]. There is also evidence of a preference for establishing healthcare facilities in high-income areas among private providers [25]. Also, the virtualization of primary care likely contribute to HCU inequalities, considering higher rates of digital HCU among individuals with higher education and income, even after adjusting for age and prevalence of chronic diseases [26]. ...
Background
Despite 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 findings
Using 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.
Conclusions
Income-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.
... Previous research demonstrates that when adjusting for patient mix and PCC list size, differences with regard to ownership disappear for most dimensions (Glenngård, 2013;Glenngård and Anell, 2017). One possible explanation is that private, compared to public, PCCs are smaller and located in more densely populated and socioeconomically favourable areas (Swedish National Audit Office, 2014; Isaksson et al., 2016Isaksson et al., , 2018Burström et al., 2017). There is a risk that the intended outcomes of choice and competition fail are areas with a high socioeconomic burden if providers choose not to establish there. ...
This study contributes to the sparse literature on differences between public and private primary care practices (PCCs). The purpose was to explore if differences in performance and characteristics between public and PCCs persist over time in a welfare market with patient choice and provider competition, where public and private providers operate under similar conditions. The analysis is based on data from a national patient survey and administrative registries in a large Swedish region, covering PCC observations in 2010 and 2019, i.e., the year after and 10 years after introducing choice and competition in the region. The findings suggest that differences across owner types tend to decrease over time in welfare markets. Differences in patients' experiences, PCC size, patient mix and the division of labour have decreased or disappeared between 2010 and 2019. There were small but significant differences in process measures of quality in 2019; public PCCs complied better with prescription guidelines. While the results demonstrate a convergence between public and private PCCs in regards to their characteristics and performance, differences in patients' experiences in regards to socioeconomic conditions persisted. Such unwarranted variation calls for continued attention from policy makers and further research about causes.
... This may indicate that the reform led to a decrease in geographical equity because more affluent areas got more new providers. In line with this, another study by Isaksson et al. [53] analysed socioeconomic differences in patients registered with private compared to public PHC centres. The results confirmed that individuals with higher socioeconomic status were more likely to be registered with a private PHC centre than individuals with lower socioeconomic status. ...
Background
In 2007, a reform of Swedish primary healthcare began when some regions implemented enhanced patient choice in combination with free establishment for private providers. Although heavily debated, in 2010 it became mandatory for all regions to implement this choice system.
Aim
The aim of this article was to review all published research articles related to the primary healthcare choice reform in Sweden, to investigate what has been published about the reform and summarise its first 15 years.
Methods
A scoping review was performed to cover the breadth of research on the reform. Searches were made in Scopus, Web of Science and PubMed for articles published between 2007 and 2021, resulting in 217 unique articles. In total, 52 articles were included.
Results
The articles were summarised and presented in relation to six overarching themes: arguments about the primary healthcare choice reform; governance and financial reimbursements; choice of provider and use of information; effects on equity and access; effects on quality; and differences between private and public primary healthcare centres.
Conclusions
The articles show that the reform has led to an increase in access to primary healthcare, but most studies indicate that the increase is inequitably distributed in terms of socioeconomy and geographical location. The effects on quality are unclear but several studies show that the mechanisms supposed to lead to quality improvements do not work as intended. Furthermore, from a population health perspective, it is time to discuss how such a responsibility can be reintegrated into primary healthcare and function with the choice system.
Patient registration with a primary care providers supports continuity in the patient-provider relationship. This paper develops a framework for analysing the characteristics of patient registration across countries; applies this framework to a selection of countries; and identifies challenges and ongoing reform efforts. Twelve jurisdictions (Denmark, France, Germany, Ireland, Israel, Italy, Netherlands, Norway, Ontario [Canada], Sweden, Switzerland, United Kingdom) were selected for analysis. Information was collected by national researchers who reviewed relevant literature and policy documents to report on the establishment and evolution of patient registration, the requirements and benefits for patients, providers and payers, and its connection to primary care reforms. Patient registration emerged as part of major macro-level health reforms linked to the introduction of universal health coverage. Recent reforms introduced registration with the aim of improving quality through better coordination and efficiency through reductions in unnecessary referrals. Patient registration is mandatory only in three countries. Several countries achieve high levels of registration by using strong incentives for patients and physicians (capitation payments). Patient registration means different things in different countries and policy-makers and researchers need to take into consideration: the history and characteristics of the registration system; the use of incentives for patients and providers; and the potential for more explicit use of patient-provider agreements as a policy to achieve more timely, appropriate, continuous and integrated care.
