Sandra Søgaard Tøttenborg1, Peter Lange2, Søren Paaske Johnsen3, Henrik Nielsen3, Truls Sylvan Ingebrigtsen4, Reimar Wernich Thomsen3. 1. Section of Social Medicine, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Postboks 2099, 1014 Copenhagen K, Denmark. Electronic address: sato@sund.ku.dk. 2. Section of Social Medicine, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Postboks 2099, 1014 Copenhagen K, Denmark; Respiratory Section, Hvidovre Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark. 3. Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark. 4. Department of Internal Medicine, Respiratory Section, Roskilde Hospital, Sygehusvej 10, 4000 Roskilde, Denmark.
Abstract
BACKGROUND: Low socioeconomic status has been associated with adverse outcomes in chronic obstructive pulmonary disease (COPD), but population-based data are sparse. We examined the impact of education, employment, income, ethnicity, and cohabitation on the risk of suboptimal adherence to inhaled medication, exacerbations, acute admissions, and mortality among COPD patients. METHODS: Using nationwide healthcare registry data we identified 13,369 incident hospital clinic outpatients with COPD during 2008-2012. We estimated medication adherence as proportion of days covered (PDC) one year from first contact. With Poisson regression we computed adjusted relative risks (aRR) of poor adherence and non-use. With Cox regression we calculated adjusted hazard ratios (aHR) of clinical outcomes. RESULTS: 32% were poor adherers (PDC<0.8) and 5% non-users (PDC = 0). Analyses showed a higher risk of poor adherence among unemployed (aRR1.36, 95% CI 1.20-1.54), low income patients (aRR = 1.07, 95% CI 1.00-1.16), immigrants (aRR = 1.29, 95% CI 1.17-1.44), and patients living alone (aRR = 1.17, 95% CI 1.11-1.24). Similarly, non-use was associated with unemployment (aRR = 2.75, 95% CI 2.09-3.62), low income (aRR = 1.37, 95% CI 1.10-1.70), immigrant status (aRR = 1.56, 95% CI 1.17-2.08), and living alone (aRR = 1.53, 95% CI 1.30-1.81). Low education was associated with exacerbations (aHR = 1.21, 95% CI 1.10-1.35) and admissions (aHR = 1.22, 95% CI 1.07-1.38). Low income was associated with admissions (aHR = 1.20, 95% CI 1.09-1.32), and death (aHR = 1.11, 95% CI 0.99-1.25). The unemployed and those living alone had lower exacerbation-risk but higher mortality-risk. CONCLUSIONS: In Denmark, health equity is a stated priority in a public health care system. Nevertheless, there are substantial socioeconomic inequalities in COPD treatment and outcomes.
BACKGROUND: Low socioeconomic status has been associated with adverse outcomes in chronic obstructive pulmonary disease (COPD), but population-based data are sparse. We examined the impact of education, employment, income, ethnicity, and cohabitation on the risk of suboptimal adherence to inhaled medication, exacerbations, acute admissions, and mortality among COPDpatients. METHODS: Using nationwide healthcare registry data we identified 13,369 incident hospital clinic outpatients with COPD during 2008-2012. We estimated medication adherence as proportion of days covered (PDC) one year from first contact. With Poisson regression we computed adjusted relative risks (aRR) of poor adherence and non-use. With Cox regression we calculated adjusted hazard ratios (aHR) of clinical outcomes. RESULTS: 32% were poor adherers (PDC<0.8) and 5% non-users (PDC = 0). Analyses showed a higher risk of poor adherence among unemployed (aRR1.36, 95% CI 1.20-1.54), low income patients (aRR = 1.07, 95% CI 1.00-1.16), immigrants (aRR = 1.29, 95% CI 1.17-1.44), and patients living alone (aRR = 1.17, 95% CI 1.11-1.24). Similarly, non-use was associated with unemployment (aRR = 2.75, 95% CI 2.09-3.62), low income (aRR = 1.37, 95% CI 1.10-1.70), immigrant status (aRR = 1.56, 95% CI 1.17-2.08), and living alone (aRR = 1.53, 95% CI 1.30-1.81). Low education was associated with exacerbations (aHR = 1.21, 95% CI 1.10-1.35) and admissions (aHR = 1.22, 95% CI 1.07-1.38). Low income was associated with admissions (aHR = 1.20, 95% CI 1.09-1.32), and death (aHR = 1.11, 95% CI 0.99-1.25). The unemployed and those living alone had lower exacerbation-risk but higher mortality-risk. CONCLUSIONS: In Denmark, health equity is a stated priority in a public health care system. Nevertheless, there are substantial socioeconomic inequalities in COPD treatment and outcomes.
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