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International Journal for Quality in Health Care Advance Access published online on December 11, 2006
International Journal for Quality in Health Care, doi:10.1093/intqhc/mzl065
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© The Author 2006. Published by Oxford University Press on behalf of the International Society for Quality in Health Care (ISQua). All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org
Accepted November 15, 2006

Article

The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: a multicity population-based longitudinal study

Nera Agabiti 1 *, Sally Picciotto 1, Giulia Cesaroni 1, Luigi Bisanti 2, Francesco Forastiere 1, Roberta Onorati 3, Barbara Pacelli 4, Paolo Pandolfi 4, Antonio Russo 2, Teresa Spadea 3, and Carlo A. Perucci 1, On Behalf of the Italian Study Group on Inequalities in Health Care *

1 Epidemiology Department, Local Health Authority RM/E, Rome
2 Epidemiology Unit, Local Health Authority, Milan
3 Epidemiology Unit, Piedmont Region, Turin
4 Epidemiology Unit, Local Health Authority, Bologna

* To whom correspondence should be addressed.
Nera Agabiti, E-mail: agabiti{at}asplazio.it


  Abstract

Objective. In countries with universal health coverage, socioeconomic status is not expected to influence access to effective treatment and its prognosis. We tested whether socioeconomic status affects the rates of elective total hip replacement and whether it plays a role in early and late outcomes.

Design. Multicity population-based longitudinal study.

Settings and participants. From Hospital Registries of four Italian cities (Rome, Milan, Turin, and Bologna), we identified 6140 residents aged 65+ years undergoing elective total hip replacement in 1997-2000.

Main outcome measures. An area-based (census block) income index was used for each individual. Poisson regression yielded rate ratios (RR) of population occurrence by income level. Logistic regression estimated odds ratios (OR) of selected outcomes within 90 days. Cox proportional hazard models evaluated effects of income on rates of revision of total hip replacement and mortality up to 31 December 2004. Analyses were adjusted for age, gender, city of residence, and coexisting medical conditions.

Results. Low-income people were less likely than high-income counterparts to undergo total hip replacement [RR = 0.87, 95% confidence interval (CI) 0.81-0.95]; the effect was stronger among those aged 75+ years (RR = 0.76, 95% CI = 0.66-0.86). Low income was associated with higher risk of acute adverse medical events (P trend = 0.05) and of general infections and decubitus ulcer (P trend = 0.02) within 90 days. The effects were even higher among those aged 75+ years. No effects were found either for orthopaedic complications within 90 days or for revision and mortality.

Conclusions. Total hip replacement is underutilized among elderly deprived individuals. Disadvantaged patients seem more vulnerable to acute adverse medical events after surgery. The evidence of unmet need and poor prognosis of low social class people has important implications for health care policy.

Keywords: access to health services, administrative data, adverse events, complications, inequalities in health, hip replacement.

*Members of the Italian Study Group on Inequalities in Health Care: Carla Ancona, Valeria Belleudi, Giulia Cesaroni, Marina Davoli, Carlo A. Perucci, Patrizia Schifano (Roma), Luigi Bisanti, Antonio Russo (Milano), Giulio Bugarini (Roma), Nicola Caranci, Claudia Galassi (Bologna), Giuseppe Costa, Chiara Marinacci, Teresa Spadea (Torino), Stefano Mattioli (Bologna), Patrizia Vittori (Valle d’Aosta), Carlo Zocchetti (Milano)


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