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Inequality in diabetes-related hospital admissions in England by socioeconomic deprivation and ethnicity

西野, 義崇 東京大学 DOI:10.15083/0002001418

2021.09.08

概要

Background: Socioeconomic inequality in health is common in both low- and high- income countries even in a country that universal health coverage (UHC) system in place such as the United Kingdom. It includes inequality in access to health care, quality of health care, and risky behavior for health. In the United Kingdom, socioeconomic inequality has persisted since it was reported in Black Report published in 1980 although several measures to reduce the inequality have been taken. However, disparity reduction did not attain the national target, especially the gap between so-called “spearhead areas” and non-spearhead areas. Inequality in health may generate high impact health care users and most of them are preventable. In growing financial constraint in the National Health Service (NHS), to address the issue of those high impact users is important. Diabetes mellitus is a typical example of non-communicable disease which sometimes causes preventable hospital admissions. Linking with socioeconomic inequalities, identifying high impact users by diabetes related admissions is required.

Objective: To investigate the association between socioeconomic deprivation and ethnicity and inpatient admissions and readmissions due to diabetes in England. And to find feasible policies to reduce inequality in the impact of diabetes on hospital admissions and readmissions as well as lower the excess burden of health care expenditure in the United Kingdom.

Design: Facility-based cross-sectional analysis of all England hospital records

Setting: NHS trusts in England reporting inpatient admissions with better than 80% data reporting quality from 2010-2011 (355 facilities). Data on individual inpatient hospital admissions and readmissions were obtained from the inpatient component of the UK Hospital Episode Statistics data from 2010 to 2011.

Participants: Non-obstetric patients over 16 years old in all NHS facilities in England. Patients who received psychiatric related treatment were excluded because they tend to stay in a hospital for extremely long years. The sample size after exclusion was 5,147,859 all-cause admissions. Patients who admitted 11 times and more admissions were excluded in the analysis of high impact users because of computational problems.

Main outcome measures: The relative risk of inpatient admission, and readmissions due to diabetes adjusted for confounders: ethnicity, broad age group (16 – 29, 30 – 44, 45 – 64, over 65) on the day of admission, and rural-urban indicator.

Statistical Analysis: Statistical Analyses were conducted for the whole admission data, the first admission data, and the data of patients who were admitted twice to 11 times. The data of men and women were analyzed separately. The relationship between regional deprivation (Index of Multiple Deprivation; IMD) and inpatient admission (whole admission data and the first admission data) was analyzed using a multiple Poisson regression model with random effects for region (the Lower Super Output Area; LSOA) and the IMD treated as a region-level variable. Population by broad age groups at the LSOA level was used as an offset in the regression model. Random intercepts by LSOA was introduced because the admission pattern may be correlated within each LSOA and the IMD is calculated at the LSOA, rather than the individual level. In order to analyze the tendency of the high impact users, the number of readmissions was analyzed by using multi-level Poisson regression. I investigated how many times a patient was admitted to hospital during the data collection period. To adjust for the varying dates of initial admission, the time at risk was treated as person-years in the analysis. The number of readmissions per person-year of risk per person was analyzed using a Poisson regression model, applied to data for those patients who had at least one diabetes-related admission during the year. The natural log of person-years was used as the offset of the Poisson regression.

Results: Across England, there were 445,504 diabetes-related hospital admissions in England in 2010, giving an age-sex standardized rate of 1049.0 per 100,000 population (95% confidence interval (CI): 1046.0-1052.1). In both of the whole admission data and the first admission data, age was significantly associated with an increased risk of admission for diabetes. Women showed different patterns of risk from men. The slope of the inequality by the IMD quintile categories and interaction effect of ethnicity and the IMD quintile categories were steeper in women. The risk was higher in urban areas than in towns or villages. Admissions were more likely through emergency than elective processes. In the whole admission data, the poorest quintile category of white British men had 1.95 times (95% CI 1.88–-2.01) and white British women had 2.32 times (95% CI 2.24-–2.40) higher admission risk than the richest quintile category. In the first admission data, the most deprived quintile category white British men had 1.96 (95% CI: 1.91–-2.02) times and white British women had 2.25 (95% CI: 2.18–-2.32) times higher admission risk than the least deprived quintile category. Non-white British showed higher risk of admission than white British. For the first admission, South Asian British men showed 3.21 times (95% CI: 2.95 – 3.48) times and South Asian British women showed 3.09 times (95% CI: 2.79 – 3.42) higher admission risk. The association between admission risk and IMD in South Asian men and women was more moderate than in white British in the whole admission data, but the association was observed only in men for the first admission data. About 32.1% of male patients and 30.9 % of female patients who were admitted due to diabetes were readmitted at least once due to the same condition. The readmission risk increased with a rise of the IMD among white British but not for the other ethnicities although the poorest South Asian men showed a slightly higher risk. The poorest quintile of white British men had a 1.17 times (95% CI 1.12 - 1.21) and white British women had 1.20 times (95% CI 1.15 - 1.26) higher readmission risk than the richest quintile category. South Asian men showed lower risk of readmission than white men (0.81, 95% CI: 0.72 – 0.90). The readmission risk was slightly higher in patients whose index admission was elective than those admitted through the emergency department. There was almost no gender difference in the associations of readmission risk with the IMD quintile categories. Most of other covariates showed no significant differences.

Discussion & Conclusions: More deprived areas had higher rates of inpatient admission and readmissions due to diabetes. South Asian British showed higher admission risk and lower readmission risk than white British after adjusting for the IMD. However, there was almost no difference by ethnicity in readmission due to diabetes. Higher admission rates in South Asian British may be explained by their higher prevalence because their lower readmission risk suggests no inequality in the quality of care. Increased risk of readmission to hospital due to diabetes was associated with socioeconomic deprivation, but only in white British. There was almost no difference in non-white ethnicities regardless of deprivation status. This suggests that prevalence alone does not account for the differences in admission risk by IMD. If the gradient in the relationship between first hospital admission and socioeconomic status is only attributable to the difference of prevalence and there is no inequality in quality of health care, differences in readmission to hospital should not exist. The two main possible causes of the increased risk of hospital admissions and readmissions in poorer areas are excess prevalence of potential individual risk factors in poorer individuals, or poorer management of diabetes in primary care/inpatient care/after discharge care in poorer areas. First diagnosis of diabetes may be vital to addressing the inequality in risk of admissions. Improvements in community awareness, primary care management, patient follow-up in poorer areas, especially the most deprived “spearhead” areas are required.

Keywords: diabetes, Index of Multiple Deprivation, ethnicity, inequality, inpatient admission, readmission

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