Equity in Treatment and Outcomes among Heart Failure Patients in Sweden : The role of gender, age and socioeconomic factors in access to treatment and mortality

Sammanfattning: There is extensive empirical evidence for inequity in health and health care between and within countries across all economic levels worldwide. In Sweden, the Health and Medical Services Act states that health care should provide good health and equal health care for the entire population, but this goal has yet to be fulfilled. Equity has been defined as “differences which are unnecessary and avoidable, but in addition are considered unfair and unjust”. Equity in health is closely linked with the so-called social determinants of health, or the conditions in which people are born, grow, live, work, and age.Heart failure (HF) is a common disease globally, carrying high morbidity and mortality, and is one of the major causes of hospitalisations in Sweden. There is a strong evidence base for renin angiotensin system blockers (RASb) as well as beta-blockers (BB) reducing mortality in HF, and long-standing recommendations for these medications in treatment guidelines. However, not all eligible patients receive this first-line treatment. There has been some evidence of inequity by gender and age in treatment of HF, but evidence regarding socioeconomic risk factors has been scarce.In this thesis, differences in access to pharmacological therapy by demographic and socioeconomic factors were investigated.Observational studies with cohort designs were performed. In Study I–III large national population-level interlinked register materials were investigated, and in Study IV a well characterised cohort including clinical and prescription data from the SwedeHF, a Swedish HF quality register, was analysed.In Study I, we investigated differences in access to angiotensin-converting enzyme inhibitors (a type of RASb) by gender, age, educational level, employment status, income and immigration status among hospitalised HF patients in Sweden. In Study II we aimed to investigate effectiveness, i.e., the association between RASb exposure and mortality, among hospitalised HF patients in Sweden, and whether effectiveness varied with gender and age. In Study III, RASb access and mortality by employment status and educational level among hospitalised HF patients in Sweden of working age was analysed, along with possible excess mortality among non-employed patients without access to RASb. In Study IV, medication adherence to mortality-reducing HF medications, i.e., RASb and BB, was examined by age, gender, educational level, marital status and income.In conclusion, the studies in the thesis showed that access to RASb treatment appeared inequitable for women, the non-employed, and the elderly among hospitalised HF patients, although this treatment was associated with lower mortality for all these groups. Furthermore, RASb treatment was associated with similar reductions in mortality for women and men, but the association was somewhat weaker among older compared with younger hospitalised HF patients. In addition, non-employment and lower educational level were associated with higher mortality in hospitalised HF patients, and non-employment was associated with less access to RASb treatment. Finally, lower income and single status were associated with lower adherence to mortality-reducing treatment with BB and RASb in a quality register HF cohort, while associations were more unclear regarding gender and age.