A register-based study of health equity in Swedish stroke and diabetes care delivery

Sammanfattning: Stroke and diabetes are relatively common conditions and have a huge impact on society’s burden of illness; over 400 million people around the world live with diabetes and 15 million have a stroke every year. Estimates on the disability-adjusted life years lost amount to 68 million due to diabetes and 120 million due to stroke annually. This burden to the individual and to society is neither ignorable nor possible to let escalate. With a very long history of diagnosis, continuous development of treatments, and extensive research on their effects (>287 thousand articles in PubMed with stroke and/or diabetes in the title), it could be expected that the highest quality of stroke and diabetes care delivery have spread across all groups of patients, no matter demographic profile, socioeconomic situation, or geographical area of residence. The aim of this thesis is to explore whether Swedish healthcare, which is universal and tax-funded, is characterized by health inequities or not, with regards to stroke and diabetes care delivery. To enable extensive analysis on what patient characteristics that may play a role in regaining health after diagnosis and to what extent, registry data from several local, regional and national sources were linked on patient level. Data included administrative data (from regional databases), disease-specific outcome and process markers on the entire chain of care (the Swedish Stroke Register and the National Diabetes Register respectively), demographic, socioeconomic and geographic information (Statistics Sweden), data on social insurance (the Swedish Social Insurance Agency), and data on municipal care such as special housing and home-help services (the National Board of Health and Welfare). These data were all part of the Sveus databases. All studies comprised analysis via multivariate regressions on health outcomes, resource use, and/or care process. There are differences in health regained and healthcare received. Women with ischemic stroke were found to have lower function (approximated modified Rankin Scale) one year after stroke whilst a larger proportion of women survived the first year compared to men. Inpatient care received (regional financing) was lower for female stroke patients whilst proportion of patients staying in special housing (municipal financing) was higher during the year prior to and the year after stroke. Women with Type 1 Diabetes had worse blood glucose control compared to men. For Type 2 Diabetes, women had better blood glucose control compared to men, but higher levels of LDL cholesterol. Younger individuals typically showed worse blood glucose control than older for both Type 1 Diabetes and Type 2 Diabetes. The socioeconomic situation of individuals afflicted with stroke and/or diabetes also seems to play a role regarding health outcomes achieved as well as care process and healthcare resources received; high educational level (>12 years) was a significant predictor for better blood glucose control in both Type 1 and Type 2 Diabetes. High educational level was also a significant positive predictor for survival first year after stroke and functional status first year after ischemic stroke (data not presented in research papers). There is also a geographic gradient in Swedish stroke care, where a few hospitals achieve significantly better health outcomes than others and a few achieve significantly worse (adjusted for differences in patient characteristics). Some hospitals showed significantly higher levels of resource use whilst other showed significantly lower levels. No clear pattern emerged regarding the included hospitals’ relationship between health outcomes achieved and resources invested. Studying health equity in Swedish stroke and diabetes care delivery, within the five studies included in this thesis, demonstrates that there are health inequities. Stroke and diabetes have been known and diagnosed in medicine for a long time and still, different groups of people receive different amount of support for their condition relative to their needs, leading to significant differences in health and health-related quality of life. To change the situation, there is work that needs to be done by the policy makers, the payers and the care providing organizations. Policy makers need to integrate health equity as part of all relevant policy development, as it is also a prioritized goal according to Swedish law. Payers (of hospital care, special housing, pharmaceutical drugs) can start adjusting their incentive models at hand towards providers, based on dimensions of health equity. Providers must then act to raise awarenesson which patients are at particularly high risk of low health outcomes.