Inequalities in access to healthcare by local policy model among newly arrived refugees: evidence from population-based studies in two German states

Background Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers' access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) and a tendency towards lower GP (OR=0.61 [0.33-1.16]) and emergency department utilization (OR=0.74 [0.48-1.14]). ASR under the EHC model showed a tendency toward higher specialist unmet needs (OR= 1.89 [0.98-3.64]) and avoidable hospitalizations (OR=1.69 [0.87-3.30]) compared to ASR with regular access. A comparison between EHC and HV showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). Conclusion ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist (and partly also GP) services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Minor differences in unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies.

Avoidable Hospitalization for Heart Failure Among a Cohort of 18- to 64-Year-Old Italian Citizens and Immigrants: Results From the Italian Network for Longitudinal Metropolitan Studies

Background: Heart failure (HF) represents a severe public health burden. In Europe, differences in hospitalizations for HF have been found between immigrants and native individuals, with inconsistent results. Immigrants face many barriers in their access to health services, and their needs may be poorly met. We aimed to compare the rates of avoidable hospitalization for HF among immigrants and native individuals in Italy. Methods: All 18- to 64-year-old residents of Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome between January 1, 2001 and December 31, 2013 were included in this multicenter open-cohort study. Immigrants from high migratory pressure countries (divided by area of origin) were compared with Italian citizens. Age-, sex-, and calendar year-adjusted hospitalization rate ratios and the 95% CIs of avoidable hospitalization for HF by citizenship were estimated using negative binomial regression models. The hospitalization rate ratios were summarized using a random effects meta-analysis. Additionally, we tested the contribution of socioeconomic status to these disparities. Results: Of the 4 470 702 subjects included, 15.8% were immigrants from high migratory pressure countries. Overall, immigrants showed a nonsignificant increased risk of avoidable hospitalization for HF (hospitalization rate ratio, 1.26 [95% CI, 0.97–1.68]). Risks were higher for immigrants from Sub-Saharan Africa and for males from Northern Africa and Central-Eastern Europe than for their Italian citizen counterparts. Risks were attenuated adjusting for socioeconomic status, although they remained consistent with nonadjusted results. Conclusions: Adult immigrants from different geographic macroareas had higher risks of avoidable hospitalization for HF than Italian citizens. Possible explanations might be higher risk factors among immigrants and reduced access to primary health care services.

Continuity in general practice and hospitalization patterns: an observational study

Background High continuity of care is a key feature of strong general practice. This study aimed to assess the effect of a programme for enhancing strong general practice care on the continuity of care in Germany. The second aim was to assess the effect of continuity of care on hospitalization patterns. Methods We performed an observational study in Germany, involving patients who received a strong general practice care programme (n=1.037.075) and patients who did not receive this programme (n=723.127) in the year 2017. We extracted data from a health insurance database. The cohorts were compared with respect to three measures of continuity of care (Usual Provider Index, Herfindahl Index, and the Sequential Continuity Index), adjusted for patient characteristics. The effects of continuity in general practice on the rates of hospitalization, rehospitalization, and avoidable hospitalization were examined in multiple regression analyses. Results Compared to the control cohort, continuity in general practice was higher in patients who received the programme (continuity measures were 12.47 to 23.76% higher, P< 0.0001). Higher continuity of care was independently associated with lowered risk of hospitalization, rehospitalization, and avoidable hospitalization (relative risk reductions between 2.45 and 9.74%, P< 0.0001). Higher age, female sex, higher morbidity (Charlson-index), and home-dwelling status (not nursing home) were associated with higher rates of hospitalization. Conclusion Higher continuity of care may be one of the mechanisms underlying lower hospitalization rates in patients who received strong general practice care, but further research is needed to examine the causality underlying the associations.

Potentially avoidable hospitalization for asthma in children and adolescents by migrant status: results from the Italian Network for Longitudinal Metropolitan Studies

Background Global migration toward Europe is increasing. Providing health assistance to migrants is challenging because numerous barriers limit their accessibility to health services. Migrants may be at a greater risk of developing asthma and receiving lower quality healthcare assistance than non-migrants. We aim to investigate whether immigrants as children and adolescents have higher rates of potentially avoidable hospitalization (PAH) for asthma compared to Italians. Methods We performed a retrospective longitudinal study using six cohorts of 2–17-year-old residents in North and Central Italy from 01/01/2001 to 31/12/2014 (N = 1,256,826). We linked asthma hospital discharges to individuals using anonymized keys. We estimated cohort-specific age and calendar-year-adjusted asthma PAH rate ratios (HRRs) and 95% confidence intervals (95%CIs) among immigrants compared to Italians. We applied a two-stage random effect model to estimate asthma PAH meta-analytic rate ratios (MHRRs). We analyzed data by gender and geographical area of origin countries. Results Three thousand three hundred four and 471 discharges for asthma PAH occurred among Italians and immigrants, respectively. Compared to Italians, the asthma PAH cohort-specific rate was higher for immigrant males in Bologna (HRR:2.42; 95%CI:1.53–3.81) and Roma (1.22; 1.02–1.45), and for females in Torino (1.56; 1.10–2.20) and Roma (1.82; 1.50–2.20). Asthma PAH MHRRs were higher only among immigrant females (MHRRs:1.48; 95%CI:1.18–1.87). MHRRs by area of origin were 63 to 113% higher among immigrants, except for Central-Eastern Europeans (0.80; 0.65–0.98). Conclusion The asthma PAH meta-analytic rate was higher among female children and adolescent immigrants compared to Italians, with heterogeneity among cohorts showing higher cohort-specific PAH also among males, with some differences by origin country. Access to primary care for children and adolescent immigrants should be improved and immigrants should be considered at risk of severe asthma outcomes and consequently targeted by clinicians.

Avoidable hospitalization in Milan’s metropolitan area: inequalities and comparison with OECD cities

Background The largest cities on the world face the unprecedented challenge of meeting the needs of a population that lives longer, has declining birthrates, and is altering the demographic profile on which social welfare programs have long been premised. This work is part of an international project aimed at comparing health and social care systems in megacities worldwide. We study access to healthcare in the metropolitan area of Milan to quantify avoidable hospital care and social inequalities within this world city, and compare Milan with other OECD megacities. Methods Two sources of data are combined: individual-level hospital discharge data to measure hospitalization for ambulatory-care sensitive conditions (ACSC), and municipality-level data collected from the national office for statistics. First, we performed an ecological analysis using a linear model for ACSC hospitalization rates to detect the risk factors in the municipality where the patient resides. Then, to identify both individual and area-level variations in population health, we use multilevel logistic regression model. Results Age-adjusted ACSC hospitalization rates continuously declined from 2005 to 2016, from 16% to 10.7%. Municipality-level risk factors include proportion of residents aged 65+ and proportion of foreigner residents. The individual-level predictors of ACSC hospitalization include being male, being single, having co-morbidities and low education. This association is only modestly attenuated when patient’s area-level characteristics are accounted. Conclusions We observed declining trends in ACSC hospitalizations and identified some patient’s as well as area-level characteristics related to avoidable hospitalization. Understanding whether ACSC hospitalization has dropped due to improvements in population health and access to healthcare or as part of the overall reduction in hospitalization rates needs to be further explored. Key messages Effective primary care can reduce hospitalization for preventable and chronic conditions. This work identifies individual and ecological factors related to avoidable hospitalization in urban settings. Policies to improve access to healthcare, tackle inequalities and reduce hospitalization costs may be more effective if targeted on individuals considering and the environment in which they live.