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- PATIENTS AND METHODS
Rheumatoid arthritis (RA) is a chronic and disabling disease that has a major impact on the lives of patients. Many patients have impaired physical health and are dependent on a wide variety of health care services (1).
Among individuals with a low socioeconomic status (SES), RA is more prevalent (2), the impact of the disease is higher (3–9), and the risk of mortality is higher (3, 10, 11). Because of these disadvantages, it is said that patients with a low SES are exposed to double suffering, having both a higher prevalence of RA and more severe RA (12).
Generally, we would expect that patients with low SES, considering they are less healthy, would use more health care. When equal access to health care is considered, the variations in the use of health care between low and high SES groups should disappear when health-related needs are taken into account (13). Equity in health care assumes that utilization of care is predominantly determined by health characteristics, because health care should be provided irrespectively of SES; inequity in health care is present if the use of care is related to enabling factors, such as SES.
With regard to the use of health care among patients with RA, it was found that socioeconomic deprivation did not lead to systematic differences in medication treatment (8, 14, 15). Moreover, it is not clear whether socioeconomic differences are present in the use of health care services among patients with RA, and whether differences in health outcomes and in use of health care decrease or increase during the course of the disease. On the one hand, differences in SES in long-term health outcomes and long-term health care utilization may decrease because later in life the survivors with a low SES represent a relatively healthy subgroup (16). On the other hand, socioeconomic differences in health outcomes and health care use may increase because of cumulative advantages experienced during life span (17). Provided that differences in SES are present, knowledge on this subject is important to determine in which part of the care process problems exist, arise, or expand. These results could be used to adjust the care process to assure equal use of care for equal needs, independent of SES.
The aim of this article is to quantify the impact of SES among patients with RA on 1) health outcomes and health care utilization in relation to disease duration and 2) changes in health outcomes and changes in health care utilization over a 2-year period.
- Top of page
- PATIENTS AND METHODS
In this study, we quantified the impact of SES among patients with RA on 1) health outcomes and health care utilization in relation to disease duration and 2) changes in health outcomes and changes in health care utilization over a 2-year period.
We analyzed health outcomes and health care utilization by means of cross-sectional and longitudinal analyses. Although cross-sectional analyses may be potentially more biased than longitudinal analyses for detecting changes in outcome measures, they have the advantage of creating a wider time span in the data.
We showed that the distribution of SES in this patient group, adjusted for age and sex, differed significantly from the general Dutch population (29). Taking into account that RA has a higher prevalence among individuals with low SES (2), one would expect more patients in the low SES group compared with the general population. In contrast, the low SES patient group contained considerably fewer patients than was expected. This might indicate a problem in the access to care of patients with low SES, either in the access to primary care or in the referral from primary care to secondary or tertiary care centers.
The results of this study confirmed findings of previous studies (3, 5, 6): patients with a low SES have worse health outcomes than patients with a high SES. However, significant differences in health outcomes between patients with high SES and patients with low SES are only present in the 0–5-year disease duration group. Irrespective of SES, patients tend to fail in health over time, in an absolute way, on the number of disabilities and on the prevalence of depressive symptoms. Relative differences in these health outcomes, however, decline between SES groups over time, as patients with a low SES grow worse less quickly than patients with a high SES.
Over a 2-year period, patients with low SES worsened on the more objective measures, i.e., physical health (HAQ) and mental health (CES-D), but improved more often than those with high SES on the overall measure of quality of life. These results indicate that patients with low SES might have a different perception or interpretation of quality of life than patients with high SES.
The principle of equity in health care presupposes that the use of health care is influenced by health characteristics and not by SES. Equity in health care was demonstrated by this study for most health care services. We found, however, that patients with low SES used less allied health care than patients with high SES, after adjusting for age, sex, and health outcomes. In the Netherlands, no financial barriers in health care are present because of regulations of the Dutch health insurance system. Therefore, no financial access problems to allied health care could be expected. Our results suggest, as mentioned in previous research (8), that higher educated people might be better equipped to negotiate for medical care, while they are not necessarily more in need of health care.
We think that the strength of this study is the longitudinal design with a large group of patients with a wide span in disease duration, combined with comprehensive assessments of health outcomes and health care utilization. However, some remarks can be made. First, a followup period of 2 years is short for detecting a SES gradient on changes in health outcomes and in the use of health care services over time, especially in the case of a progressive chronic condition like RA. Second, we might have overestimated the SES differences in health outcomes in our study, especially among women, because we used formal education level of the patient to assign patients to the various SES groups. We did not take into account that patients could benefit from the socioeconomic circumstances of a higher educated partner. Finally, a bias might be present in our data because no information is available on patients with RA who have not (yet) been seeking care. A bias occurs if patients from lower socioeconomic groups with milder onset RA are less likely to seek medical advice, in comparison with patients from privileged groups, resulting in an overestimation of SES differences.
In conclusion, patients with low SES have worse health outcomes than patients with high SES, but during the course of the disease the differences in health outcomes between SES groups decrease. Regarding most health care services, equity in use was demonstrated. With respect to the use of allied health care, however, we found that patients with a low SES used considerably less care than patients with a high SES. Thus, efforts should be undertaken in health care to alleviate the health disadvantages of RA patients in lower socioeconomic groups. In particular, the access to allied health care could be improved for RA patients with low SES.