Promoting equity in healthcare use requires to respect both principles of horizontal equity, that guarantees everyone the same use of healthcare for a given level of need, and vertical equity, that requires the sickest to receive more care than others, in a proportion deemed appropriate. This study explores the extent to which horizontal and vertical equity in healthcare use among individuals aged 50+ in Europe has been restructured during the COVID-19 pandemic. Using the variance as an inequality measure, we assess horizontal equity in healthcare use based on the fairness gap approach and propose two new measures of vertical equity. The sample includes 24,965 respondents of the SHARE survey from 18 European countries, who participated in wave 8 just before the pandemic and the second SHARE Corona survey in 2021. These data provide information on use of physician and hospital care over the year for each period, as well as on a wide range of health and socio-economic variables. Although pro-rich inequities in healthcare use were observed in some countries before the outbreak, our results do not reveal any significant evolution in horizontal equity during the pandemic. Conversely, vertical equity in healthcare use would have significantly declined in most countries, especially in Central or Eastern Europe. Telemedicine appears to have played a protective role against this decline in vertical equity in countries where it was heavily used during the pandemic. Our results support the case for public policies aimed at restoring access to care for individuals with the highest needs.

BACKGROUND: Pain is a prevalent side-effect seen in breast cancer survivors (BCS). Psychological factors are known role-players in pain mechanisms. Both pain and psychological factors contribute to or interact with healthcare use (HCU). However, the association between psychological factors and HCU has never been investigated in BCS with pain, which is aimed in this study.
METHODS: Belgian BCS with pain (n = 122) were assessed by the Medical Consumption Questionnaire, Injustice Experienced Questionnaire, Pain Catastrophizing Scale, Pain Vigilance and Awareness Questionnaire, Brief Illness Perceptions Questionnaire, and the Depression, Anxiety and Stress Scale. Associations were analyzed using logistic and Poisson regressions.
RESULTS: Opioid use was related to more catastrophizing and less psychological distress. Psychotropic drug was related to more psychological distress. Endocrine therapy related to less vigilance and awareness. Psychological distress related to all types of healthcare provider (HCP), with psychological distress negatively related to physiotherapy, psychology, and other primary HCP visits, and positively with visiting a general practitioner and secondary HCP. Catastrophizing related to more visiting behavior in primary HCP, except to a general practitioner. Perceived injustice related to more general practitioner and other primary HCP visits, but to fewer psychology visits. Illness perceptions are only related to visiting other primary HCP. Vigilance and awareness was related to more psychologist and secondary HCP visits.
CONCLUSIONS: Our findings underscore the complex interplay between HCU and psychological factors in BCS with pain. Psychological distress was overall the most important psychological factor related to HCU, whether catastrophizing and perceived injustice were the most relevant related to HCP visits.

The purpose of this study was to determine the healthcare utilization patterns in a national sample of older adults across several social determinants of health factors (ethnicity, gender, race, education) with normal and dementia/impaired cognition. We used datasets from the Health and Retirement Study (HRS, 2018) to evaluate healthcare utilization, including metrics such as hospital and nursing home stays, hospice care, and number of visits to the doctor. Logistic models were used to predict healthcare utilization separately in those with normal cognition and dementia. Our final sample comprised 15,607 adults (mean age: 65.2 normal cognition, mean age 71.5 dementia). Hispanics with normal cognition were less likely to stay in a hospital than non-Hispanic respondents (OR: 0.52-0.71, p<0.01). Being female was associated with a higher risk for shorter nursing home days (OR: 1.41, p<0.01) and doctor visits (OR: 1.63-2, p<0.01) in cognitively normal older adults. Being female was associated with a lower risk for hospital stay in those with dementia (OR: 0.50-0.78, p<0.01). Respondents identifying as Black or other races with dementia were less likely to experience nursing home days (OR: 0.42, p<0.04). Black respondents with normal cognition were less likely to experience doctor visits (OR: 0.32-0.37, p<0.01). Those with more than a high school education in both groups were more likely to experience doctors\' visits. The study points to the continued disparities in healthcare utilization linked to participants\' social determinants of health factors and cognition.

BACKGROUND: Lower respiratory tract infections (LRTIs) have an immediate significant impact on morbidity and mortality among older adults. However, the impact following the infectious period of LRTI remains understudied. We aimed to assess the short- to long-term impact of LRTIs on hospitalization, mortality, and healthcare utilization in older adults.
METHODS: Data from the Swedish National Study of Aging and Care in Kungsholmen (SNAC-K) was analyzed, with data from 2001 to 2019 for mortality and 2001-2016 for healthcare utilization. LRTI-exposed participants were identified and matched with LRTI-nonexposed based on sociodemographics, lifestyle factors, and functional and clinical characteristics. Statistical models evaluated post-LRTI hospitalization risk, days of inpatient hospital admissions, healthcare visits, and mortality.
RESULTS: 567 LRTIs-exposed participants during the study period and were matched with 1.701 unexposed individuals. LRTI-exposed individuals exhibited increased risk of hospitalization at 1-year (HR 2.14, CI 1.74, 2.63), 3-years (HR 1.74, CI 1.46, 2.07), and 5-years (HR 1.59, CI 1.33, 1.89). They also experienced longer post-LRTI hospital stays (IRR 1.40, CI 1.18, 1.66), more healthcare visits (IRR 1.47, CI 1.26, 1.71), specialist-care visits (IRR 1.46, CI 1.24, 1.73), and hospital admissions (IRR 1.57, CI 1.34, 1.83) compared to nonexposed participants over 16-years of potential follow-up. Additionally, the 19-year risk of mortality was higher among LRTI-exposed participants (HR 1.45, CI 1.24, 1.70). Men exhibited stronger associations with these risks compared to women.
CONCLUSIONS: LRTIs pose both short- and long-term risks for older adults, including increased risks of mortality, hospitalization, and healthcare visits that transpire beyond the acute infection period, although these effects diminish over time. Men exhibit higher risks across these outcomes compared to women. Given the potential preventability of LRTIs, further public health measures to mitigate infection risk are warranted.

BACKGROUND: The burden of chronic kidney disease (CKD) is high in the Northern Territory (NT), Australia. This study aims to describe the healthcare use and associated costs of people at risk of CKD (e.g. acute kidney injury, diabetes, hypertension, and cardiovascular disease) or living with CKD in the NT, from a healthcare funder perspective.
METHODS: We included a retrospective cohort of patients at risk of, or living with CKD, on 1 January 2017. Patients on kidney replacement therapy were excluded from the study. Data from the Territory Kidney Care database, encompassing patients from public hospitals and primary health care services across the NT was used to conduct costing. Annual healthcare costs, including hospital, primary health care, medication, and investigation costs were described over a one-year follow-up period. Factors associated with high total annual healthcare costs were identified with a cost prediction model.
RESULTS: Among 37,398 patients included in this study, 23,419 had a risk factor for CKD while 13,979 had CKD (stages 1 to 5, not on kidney replacement therapy). The overall mean (± SD) age was 45 years (± 17), and a large proportion of the study cohort were First Nations people (68%). Common comorbidities in the overall cohort included diabetes (36%), hypertension (32%), and coronary artery disease (11%). Annual healthcare cost was lowest in those at risk of CKD (AUD$7,958 per person) and highest in those with CKD stage 5 (AUD$67,117 per person). Inpatient care contributed to the majority (76%) of all healthcare costs. Predictors of increased total annual healthcare cost included more advanced stages of CKD, and the presence of comorbidities. In CKD stage 5, the additional cost per person per year was + $53,634 (95%CI 32,769 to 89,482, p < 0.001) compared to people in the at risk group without CKD.
CONCLUSIONS: The total healthcare costs in advanced stages of CKD is high, even when patients are not on dialysis. There remains a need for effective primary prevention and early intervention strategies targeting CKD and related chronic conditions.

OBJECTIVE: Functional somatic symptoms (FSS) accumulate within families. Exposure to family patterns of high healthcare use may induce maladaptive symptom coping and thereby potentially contribute to the transgenerational transmission of FSS. This study aimed to uncover associations between parental and child healthcare use during the child\'s first years of life (age 0-4) and childhood FSS at age 5-7.
METHODS: We utilized data from the Copenhagen Child Cohort (CCC2000), a population-based birth cohort. Parent-reported FSS of their 5-7-year-old children were linked to Danish national registry data on parental and child healthcare use (including general practitioner [GP] consultations and hospital contacts) during child age 0-4 years. Logistic regression analyses were performed to investigate longitudinal associations between family healthcare use and child FSS.
RESULTS: We found an association between prior parental healthcare use and child FSS at age 5-7 (OR = 1.02, 95% CI [1.01-1.04]). Key sensitivity analyses specifically focusing on GP consultations, revealed modest but statistically significant associations between parental (OR = 1.03, 95% CI [1.02-1.05]) and child (OR = 1.18, 95% CI [1.04-1.34]) GP consultations and impairing FSS at age 5-7.
CONCLUSIONS: Family healthcare use, especially within the general practice, may play a role in the transgenerational transmission of FSS. Early-stage FSS identification and care might be improved through training aimed at GPs. Future research may identify vulnerable families at whom parent-focused interventions for symptom-coping could be targeted. This could potentially contribute to the prevention of transgenerational transmission of FSS.

BACKGROUND: Precariousness has been associated with an increase in breast cancer mortality, but the links between precariousness, stage at diagnosis and care pathways are little explored. The objective of the DESSEIN study was to assess the impact of precariousness on disease and care pathways.
METHODS: Prospective observational study in Île-de-France comparing precarious and non-precarious patients consulting for breast cancer and followed for 1 year.
RESULTS: In total, 875 patients were included between 2016 and 2019 in 19 institutions: 543 non-precarious patients and 332 precarious patients. Precarious patients had a more advanced stage at diagnosis (55% T1 vs. 63%, 30% N+ vs 19%, P=0.0006), had a higher risk of not receiving initially planned treatment (4 vs. 1%, P=0.004), and participated less in clinical trials (5 vs. 9%, P=0.03). Non-use of supportive oncology care was 2 times more frequent among patients in precarious situations (P<0.001). During treatment, 33% of deprived patients reported a loss of income, compared with 24% of non-deprived patients (P<0.001). At 12 months from diagnosis, lay-offs were 2 times more frequent in precarious patients (P=0.0001).
CONCLUSIONS: Precariousness affects all stages of the cancer history and care pathway. Particular attention needs to be paid to vulnerable populations, considering issues of accessibility and affordability of care, health literacy and possible implicit bias from the care providers.

Rationale: Existing work suggests that patients with chronic obstructive pulmonary disease (pwCOPD) presented less frequently to the emergency department and were less likely to be hospitalized during the coronavirus disease (COVID-19) pandemic, but it is unclear if this was due to improved health and disease management or to increased barriers and/or avoidance of health care. Objectives: The objective of this study was to determine the impact of the pandemic on inpatient and outpatient healthcare use, disease incidence, and mortality rates in pwCOPD. Methods: A retrospective population-based analysis using linked administrative datasets from Alberta, Canada 18 months before and after March 12, 2020 was conducted to measure hospitalization, emergency department and outpatient visits, and COPD outpatient exacerbations during these time periods. Mortality data were also analyzed before versus after the pandemic, taking confirmed COVID-19 infection within 30 days into account. Subgroup analysis based on COPD exacerbation risk stratification was undertaken to determine if healthcare use differed based on exacerbation risk. Finally, sex-based analysis of healthcare use during the pandemic was also completed. Results: Hospitalization or emergency department visits and outpatient treatment for acute exacerbations of COPD dropped, whereas total outpatient COPD visits, including both virtual and in person, increased during the pandemic for pwCOPD. The mortality rate increased even after adjusting for COVID-19-associated deaths. Sex-based subgroup analysis showed a greater drop in acute care use for females, but the rise in mortality was seen for both sexes, with men experiencing a greater rate of mortality than women. Conclusions: Overall, pwCOPD accessed acute care resources less during the pandemic, which may have contributed to a rise in non-COVID-19 all-cause mortality.

BACKGROUND: Existing knowledge on healthcare use and costs in the last months of life is often limited to one patient group (i.e., cancer patients) and one level of healthcare (i.e., secondary care). Consequently, decision-makers lack knowledge in order to make informed decisions about the allocation of healthcare resources for all patients. Our aim is to elaborate the understanding of resource use and costs in the last six months of life by describing healthcare use and costs for all causes of death and by all levels of formal care.
METHODS: Using five national registers, we gained access to patient-level data for all individuals who died in Norway between 2009 and 2013. We described healthcare use and costs for all levels of formal care-namely primary, secondary, and home- and community-based care -in the last six months of life, both in total and differentiated across three time periods (6-4 months, 3-2 months, and 1-month before death). Our analysis covers all causes of death categorized in ten ICD-10 categories.
RESULTS: During their last six months of life, individuals used an average of healthcare resources equivalent to €46,000, ranging from €32,000 (Injuries) to €64,000 (Diseases of the nervous system and sense organs). In terms of care level, 63% of healthcare resources were used in home- and community-based care (i.e., in-home nursing, practical assistance, or nursing home care), 35% in secondary care (mostly hospital care), and 2% in primary care (i.e., general practitioners). The amount and level of care varied by cause of death and by time to death. The proportion of home- and community-based care which individuals received during their last six months of life varied from 38% for cancer patients to 92% for individuals dying with mental diseases. The shorter the time to death, the more resources were needed: nearly 40% of all end-of-life healthcare costs were expended in the last month of life across all causes of death. The composition of care also differed depending on age. Individuals aged 80 years and older used more home- and community-based care (77%) than individuals dying at younger ages (40%) and less secondary care (old: 21% versus young: 57%).
CONCLUSIONS: Our analysis provides valuable evidence on how much healthcare individuals receive in their last six months of life and the associated costs, broken down by level of care and cause of death. Healthcare use and costs varied considerably by cause of death, but were generally higher the closer a person was to death. Our findings enable decision-makers to make more informed resource-allocation decisions and healthcare planners to better anticipate future healthcare needs.

This study estimates and decomposes components of different measures of inequality in health and healthcare use among millennial adolescents, a sizeable cohort of individuals at a critical stage of life. Administrative data from the UK Hospital Episode Statistics are linked to Next Steps, a survey collecting information about millennials born between 1989 and 1990, providing a uniquely comprehensive source of health and socioeconomic variables. Socioeconomic inequalities in psychological distress, long-term illness and the use of emergency and outpatient hospital care are measured using a corrected concentration index. Shapley-Shorrocks decomposition techniques are employed to measure the relative contributions of childhood socioeconomic circumstances to adolescents\' health and healthcare inequality of opportunity. Results show that income-related deprivation contributes to significant inequalities in mental and physical health among adolescents aged between 15 and 17 years old. There are also pro-rich inequalities in the use of specific outpatient hospital services (e.g., orthodontic and mental healthcare), while pro-poor disparities are found in the use of emergency care services. Regional and parental circumstances are leading factors in influencing inequality of opportunity in the use of hospital care among adolescents. These findings shed light on the main drivers of health inequalities during an important stage of human development and have potentially important implications on human capital formation across the life-cycle.