Socioeconomic inequalities in primary-care and specialist physician visits: a systematic review

Lueckmann, Sara Lena; Hoebel, Jens; Roick, Julia; Markert, Jenny; Spallek, Jacob; von dem Knesebeck, Olaf; Richter, Matthias

doi:10.1186/s12939-020-01375-1

International Journal for Equity in Health

Table 2 Results on relationships between socioeconomic status and utilization of primary-care and specialist physicians

From: Socioeconomic inequalities in primary-care and specialist physician visits: a systematic review

author	countries	age group	time	physician	utilisation	SES measure	need-adjusted	result
Abasolo, Saez, López-Casasnovas [15]	Spain	≥ 15 years	4 weeks	primary care	frequency	household income	↓	o
Abasolo, Saez, López-Casasnovas [15]	Spain	≥ 15 years	4 weeks	specialist	frequency	household income	↓	o
Agerholm et al. [16]	Sweden	25 to 64 years	12 months	primary care	frequency	adjusted household income	↑	o⁴
		25 to 64 years		specialist				+
		65 to 84 years		primary care				o⁴
		65 to 84 years		specialist				+
Allin [17]	Canada	≥ 15 years	12 months	primary care	probability	adjusted household income	↑	+
				primary care	frequency			o
				specialist	probability			+
				specialist	frequency			+
Asada, Kephart [18]	Canada	≥ 20 years	12 months	primary care	probability	education	↑	+
					probability	adjusted household income		+
					conditional frequency	education		–
					conditional frequency	adjusted household income		–
				specialist	probability	education		+
					probability	adjusted household income		+
					conditional frequency	education		+
					conditional frequency	adjusted household income		o
Bago d’Uva, Jones, van Doorslaer [19]	Austria, Belgium, Denmark, Finland, Greece, Ireland, Italy, Netherlands, Portugal, Spain	≥ 16 years	12 months	primary care	frequency	adjusted household income	↑	−⁵
Bago d’Uva, Jones, van Doorslaer [19]		≥ 16 years	12 months	specialist	frequency	adjusted household income	↑	+
Baron-Epel, Garty, Green [20]	Israel	≥ 21 years	4 weeks	primary care	probability	education	↑	–
				primary care		household income		–
				specialist		education		+
				specialist		household income		o
Beckman, Anell [21]	Sweden	25 to 44 years	2 years	primary care	probability	household income	↓	+
		45 to 64 years						o⁴
		65 to 84 years						+
Bergmann, Kalcklösch, Tiemann [22]	Germany	≥ 18 years	12 months	primary care	frequency	index	↑	–
Bourke [23]	Ireland	≥ 16 years	12 months	primary care	probability	adjusted household income	↑	o
					frequency			–
					conditional frequency			–
				specialist	probability			+
					frequency			o
					conditional frequency			–
Bremer, Wübker [24]	Germany	≥ 50 years	12 months	primary care	probability	education	↑	o
					probability	adjusted household income		o
					conditional frequency	education		o
					conditional frequency	adjusted household income		o
				specialist	probability	education		o
					probability	adjusted household income		+
					conditional frequency	education		o
					conditional frequency	adjusted household income		+
Bremer, et al. [25]	Pooled Data from 16 European Countries	≥ 50 years	12 months	primary care	frequency	education	↑	–
Crespo-Cebada, Urbanos-Garrido [26]	Spain	≥ 50 years	12 months	primary care	probability	education	↑	o
					probability	adjusted household income		o
					conditional frequency	education		o
					conditional frequency	adjusted household income		o
Devaux, de Looper [27]	Austria, Belgium, Canada, Czech Republic, Denmark, Estonia, Finland, France, Hungary, Ireland, New Zealand, Poland, Slovak Republic, Slovenia, Spain, Switzerland, UK	≥ 15 years	12 months¹	primary care	probability	adjusted household income	↑	o⁵
				primary care	frequency			o⁵
				specialist	probability			+ ⁵
				specialist	frequency			+ ⁵
Fjaer, et al. [28]	Austria, Belgium, Czech Republic, Denmark, Estonia, Finland, France, Germany, Hungary, Ireland, Israel, Lithuania, Netherlands, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland, UK	25 to 75 years	12 months	primary care	probability	education	↑	o⁵
Fjaer, et al. [28]		25 to 75 years	12 months	specialist	probability	education	↑	+ ⁵
Garrido-Cumbrera, et al. [29]	Spain	≥ 16 years	4 weeks	primary care	probability	occupation	↑	–
Garrido-Cumbrera, et al. [29]	Spain	≥ 16 years	4 weeks	specialist	probability	occupation	↑	+
Glazier et al. [30]	Canada	20 to 79 years	2 years	primary care	probability	education	↑	o
					probability	adjusted household income		o
					conditional frequency	education		–
					conditional frequency	adjusted household income		–
				specialist	probability	education		+
					probability	adjusted household income		o
					conditional frequency	education		+
					conditional frequency	adjusted household income		o
Gonzalez-Alvarez, Barranquero [31]	Spain	≥ 16 years	12 months	primary care	probability	education	↑	–
					probability	adjusted household income		o
					frequency	education		–
					frequency	adjusted household income		o
					conditional frequency	education		–
					conditional frequency	adjusted household income		o
				specialist	probability	education		+
					probability	adjusted household income		+
					frequency	education		+
					frequency	adjusted household income		+
					conditional frequency	education		o
					conditional frequency	adjusted household income		o
Grasdal, Monstad [32]	Norway	16 to 69 years	12 months	primary care	probability	adjusted household income	↑	o
				primary care	conditional frequency			o
				specialist	probability			+ ⁶
				specialist	conditional frequency			o
Gruber, Kiesel [33]	Germany	50 to 90 years	12 months	specialist	probability	education	↑	o⁴
					probability	adjusted household income		o⁴
					frequency	education		o
					frequency	adjusted household income		o
Habicht, Kunst [34]	Estonia	25 to 74 years	6 months	primary care	probability	education	↑	o
				primary care		adjusted household income		+
				specialist		education		+
				specialist		adjusted household income		+
Hansen, et al. [35]	Norway	30 to 87 years	12 months	primary care	probability	education	↑	o
						household income		o
						occupation		o
					conditional frequency	education		o⁴
						household income		–
						occupation		o
Hoebel, et al. [12]	Germany	18 to 69 years	12 months	primary care	probability	index	↑	o
				primary care	conditional frequency			–
				specialist	probability			+
				specialist	conditional frequency			o
Hoeck, et al. [36]	Belgium	≥ 65 years	2 months	primary care	probability	education	↑	o
				primary care		adjusted household income		o
				specialist		education		o
				specialist		adjusted household income		o
Hoeck, et al. [37]	Belgium	≥ 16 years	2 months	primary care	probability	education	↑	o
					probability	adjusted household income		o
					conditional frequency	education		o
					conditional frequency	adjusted household income		o
				specialist	probability	education		+
					probability	adjusted household income		o
					conditional frequency	education		o
					conditional frequency	adjusted household income		o
		≥ 65 years		primary care	probability	education	↑	o
					probability	adjusted household income		o
					conditional frequency	education		o
					conditional frequency	adjusted household income		o
				specialist	probability	education		+
					probability	adjusted household income		o
					conditional frequency	education		o
					conditional frequency	adjusted household income		o
Korda, et al. [38]	Australia	53 to 58 years	12 months	primary care	probability	occupation	↑	o
				primary care	conditional frequency			o
				specialist	probability			+
				specialist	conditional frequency			o
La Parra-Casado, et al. [39]	Spain	≥ 16 years	4 weeks	primary care	probability	occupation	↑	o
Lichte [40]	Germany	≥ 18 years	3 months	primary care	conditional frequency	education	↑	o
Lichte [40]	Germany	≥ 18 years	3 months	primary care	conditional frequency	household income	↑	o
Lostao, et al. [41]	UK	≥ 16 years	2 weeks²	primary care	probability	occupation	↑	o
	UK			specialist				o
	Spain			primary care				–
	Spain			specialist				+
Lu, et al. [42]	Hong Kong	≥ 16 years	1 months	primary care	probability	income	↑	+
				primary care	frequency			+
				specialist	probability			o
				specialist	frequency			o
Masseria, Giannoni [43]	Italy	> 16 years	4 weeks	primary care	probability	education	↑	–
				primary care		adjusted household income		+
				specialist		education		+
				specialist		adjusted household income		o
McDonald, Conde [44]	Canada	55 to 79 years	12 months	primary care	probability	education	↑	+
					probability	adjusted household income		+
					conditional frequency	education		o
					conditional frequency	adjusted household income		o
				specialist	probability	education		+
					probability	adjusted household income		+
					conditional frequency	education		+
					conditional frequency	adjusted household income		o
Mosquera, et al. [45]	Sweden	16 to 25 years	3 months	primary care	probability	household income	↑	–
Nolan [46]	Ireland	≥ 16 years	12 months	primary care	frequency	education	↑	o
Nolan [46]	Ireland	≥ 16 years	12 months	primary care	frequency	adjusted household income	↑	o
Palència, et al. [47]	Spain	≥ 16 years	4 weeks	primary care	probability	occupation	↑	–
Palència, et al. [47]	Spain	≥ 16 years	4 weeks	specialist	probability	occupation	↑	+
Põlluste, Kalda, Lember [48]	Estonia	65 to 74 years	12 months	primary care	probability	education	↑	o
				primary care		adjusted household income		o
				specialist		education		o
				specialist		adjusted household income		o
Rattay et al. [49]	Germany	18 to 79 years	12 months	primary care	probability	index	↓	–
Regidor, et al. [50]	Spain	16 to 74 years	2 weeks	primary care	probability	education	↑	–
						adjusted household income		–
						occupation		–
				specialist		education		+
						adjusted household income		+
						occupation		+
Reibling, Wendt [51]	Austria, Belgium, Denmark, France, Germany, Greece, Italy, Netherlands, Spain, Sweden, Switzerland	≥ 50 years	12 months	specialist	probability	education	↑	+ ⁵
Rogowski et al. [52]	USA	≥ 65 years	12 months	primary care	frequency	education	↑	o
				primary care		adjusted household income		o
				specialist		education		+
				specialist		adjusted household income		o
Ryvicker, Gallo, Fahs [53]	USA	60 to 99 years	12 months	primary care	probability	education	↑	+
San Sebastian, Mosquera, Gustafsson [54]	Sweden	18 to 84 years	3 months	primary care	probability	income	↑	+
San Sebastian, Mosquera, Gustafsson [54]	Sweden	18 to 84 years	3 months	specialist	probability	income	↑	o
Schnitzer, et al. [55]	Germany	18 to 79 years	12 months	specialist	frequency	education	↑	+
Schulz [56]	Pooled Data from 13 European Countries	≥ 40 years	12 months	primary care	frequency	education	↑	–
Schulz [56]	Pooled Data from 13 European Countries	≥ 40 years	12 months	specialist	frequency	education	↑	+
Stirbu, et al. [11]	Belgium, Estonia, France, Germany, Hungary, Ireland, Latvia, Netherlands, Norway	≥ 15 years	12 months³	primary care	probability	education	↑	o⁵
Stirbu, et al. [11]		≥ 15 years	12 months³	specialist	probability	education	↑	+
Suominen-Taipale, et al. [57]	Finland	65 to 74 years	12 months	primary care	probability	education	↑	o
	Finland			specialist				+
	Norway			primary care				+
	Norway			specialist				+
Tavares, Zantomio [58]	Italy	≥ 50 years	12 months	primary care	frequency	education	↑	–
	Italy			specialist				+
	Spain			primary care				–
	Spain			specialist				+
	Portugal			primary care				+
	Portugal			specialist				+
Terraneo [10]	Pooled Data from 12 European Countries	≥ 50 years	12 months	primary care	probability	education	↑	o
Terraneo [10]	Pooled Data from 12 European Countries	≥ 50 years	12 months	specialist	probability	education	↑	+
Thode et al. [59]	Germany	18 to 79 years	12 months	primary care	frequency	index	↑	–
Tille, et al. [60]	Germany	≥ 18 years	12 months	primary care	frequency	education	↑	–
Tille, et al. [60]	Germany	≥ 18 years	12 months	specialist	frequency	education	↑	o
van Doorslaer, Koolman, Jones [61]	Austria, Belgium, Denmark, Germany, Greece, Ireland, Italy, Luxemburg, Netherlands, Portugal, Spain, UK	≥ 16 years	12 months	primary care	probability	adjusted household income	↑	o⁵
					frequency			−⁵
					conditional frequency			−⁵
				specialist	probability			+ ⁵
					frequency			+ ⁵
					conditional frequency			o⁵
van Doorslaer, Masseria, Koolman [62]	Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK	≥ 16 years	12 months	primary care	probability	adjusted household income	↑	o⁵
				primary care	conditional frequency			−⁵
				specialist	probability			+
				specialist	conditional frequency			+ ⁵
van Ourti [63]	Belgium	> 15 years	12 months	primary care	frequency	adjusted household income	↑	–
van Ourti [63]	Belgium	> 15 years	12 months	specialist	frequency	adjusted household income	↑	o
Vasquez, Paraje, Estay [64]	Chile	≥ 18 years	3 months	primary care	probability	adjusted household income	↑	+
				primary care	frequency			+
				specialist	probability			+
				specialist	frequency			+
Vedsted et al. [65]	Denmark	20 to 34 years	12 months	primary care	conditional frequency	education	↑	o
		35 to 49 years						o
		50 to 64 years						o⁴
Vedsted, Olesen [66]	Denmark	20 to 64 years	12 months	primary care	conditional frequency	education	↑	o⁴
Vikum, et al. [67]	Norway	≥ 20 years	12 months	primary care	probability	education	↑	o⁴
		20 to 67 years		primary care		income		o⁴
		≥ 20 years		specialist		education		+
		20 to 67 years		specialist		income		+
Vikum, Krokstad, Westin [68]	Norway	≥ 20 years	12 months	primary care	probability	education	↑	–
				primary care		adjusted household income		o
				specialist		education		+
				specialist		adjusted household income		+

¹, deviating for probability in Denmark: 3 months; and for frequency in some EHIS countries: 4 weeks
², deviating for outpatient consultations in UK: 3 months
³, deviating for consultations in Netherlands and Belgium: 2 months
⁴, significant results only in gender-specific subgroup-analyses
⁵, results differ for several countries, only the most frequent results are reported
⁶, only for private specialists; results for hospital outpatient visits are non-significant
+, higher utilization in the most advantaged; o, no significant differences; -, higher utilization in the most deprived
↑, adjustment for at least gender, age and any general health variable (e.g., self-rated health or chronic conditions); ↓, relevant adjustments for need have not been conducted

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