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Determinants of healthcare utilization in Greece: Implications for decision-making

Determinants of healthcare utilization in Greece: Implications for decision-making Objective: To explore factors influencing the utilization of primary and secondary healthcare in Greece. Methods: A national, geographically stratified sample was randomly selected. From November 2001 to March 2002, 5000 questionnaires were mailed, 4427 were actually received, and 1819 were completed and returned (response rate 41%). The questionnaire investigated respondents’ characteristics and their health services utilization. A number of potential utilization determinants were explored, such as region, gender, age, education, income, insurance coverage, number of family members, self-rated health status, country of birth, and parents’ country of birth. Results: The utilization of primary healthcare services depended on self-rated health status, age, income, gender, and region. Individuals with moderate and poor self-rated health, older people, women, and residents of the region of Epirus showed increased utilization of primary healthcare services. Income was a factor affecting the utilization of primary healthcare only at lower income levels. The frequency of visits for primary healthcare was negatively correlated with self-rated health status and increased as self-evaluation of health status worsened. Hospitalization was associated with self-rated health and insurance coverage for primary healthcare. Individuals with better self-rated health status, as well as those who were covered by health insurance for primary care, showed decreased hospital care utilization. The frequency of hospitalization depended on region and lower evaluations of health status. Conclusion: The findings of our research are encouraging, since they suggest that the utilization of health services in Greece is mostly determined by health status rather than other socioeconomic factors. It is believed that similar studies should be conducted in the country, since they can improve health service planning and reinforce decision-making towards healthcare resource allocation according to healthcare needs. Key words: Healthcare utilization determinants, health services utilization, primary healthcare, secondary healthcare Introduction The establishment of the NHS aimed at universal coverage of the Greek population and the reduction The health economics literature acknowledges var- of inequities in both the financing and access to ious factors that influence the utilization of health- healthcare, primarily through the widespread dis- care. Structural and organizational issues of the tribution of public primary healthcare facilities. healthcare sector, the existence of universal health More than two decades later, it seems that the coverage, as well as the type of health insurance are NHS has not yet achieved its initial goals. Greece factors that determine healthcare utilization. These, is among the OECD countries with the highest when combined with other socioeconomic, demo- healthcare spending as a percentage of gross domes- graphic, and epidemiological characteristics, are tic product (10% of GDP in 2006). Eighty-five per factors that significantly influence healthcare utiliza- cent of the Greek population is insured for primary tion (113). healthcare, 94% for hospitalization in the public The various socioeconomic, demographic, and sector, and approximately 8% has private health epidemiological changes that have taken place in insurance. Direct out-of-pocket and informal pay- Greece since the enactment of the NHS Law in 1983 ments are the highest in the European Union, have made the study of health services utilization a corresponding to 48% of total health expenditure, subject of major importance, especially at a time while payments from private health insurance ac- when healthcare reforms are being challenged. count only for about 2% (1417). Possible reasons Correspondence: Mary Geitona, Department of Economics, Korai 43 str., University of Thesally, Volos 38 333, Greece. Tel: 30 24210 74917/210 6211 591. E-mail: [email protected] (Accepted 15 June 2007) ISSN 1381-4788 print/ISSN 1751-1402 online # 2007 Taylor & Francis DOI: 10.1080/13814780701541340 Healthcare utilization in Greece 145 for the high private spending are the fragmentation significant factors that affect the number of visits in the provision of primary healthcare, the lack of (1) to healthcare providers. Both logistic and comprehensiveness in the social insurance coverage, Poisson regressions were performed by a step-wise limited access to healthcare provision, regional method. inequalities in resource allocation, and undersupply The independent variables that were included in of technological equipment in the public sector the model were the following: a) region (12 dummy (14,17). variables were created for 13 geographical regions), The objective of this study was to determine the b) gender (binary variable), c) country of birth factors that influence the utilization of primary and (binary variable, Greece versus elsewhere), d) coun- secondary healthcare in Greece. The results of the try of parents’ birth (binary variable, Greece versus study would contribute to the existing literature by elsewhere), e) age (numeric), f) education (nu- providing health policy decision-makers with in- meric), g) primary health insurance (binary vari- sights into how to manage both socioeconomic able), h) secondary health insurance (binary inequalities and health resources. variable), i) income (five-scale ordinal variable), and j) self-rated health (five-scale ordinal variable). In order to treat and compare the different Methods categories of the five-scale ordinal variables, Helmert A national, geographically stratified (one-stage coding was used. Finally, the Pearson chi-square method) sample of 5000 individuals was randomly goodness-of-fit test (18) was used to check the selected from the national phone directory. Self- models’ goodness of fit. administered questionnaires were sent during the period November 2001 to March 2002. The ques- Results tionnaires asked for information regarding respon- dents’ characteristics and their utilization of primary After two rounds of mailings, the response rate to the and secondary healthcare. Of the 5000 question- survey was 41%. According to the data collected, naires sent, 4427 were actually received due to 50% of the sample population utilized primary residence changes, deaths, etc.; 1819 of these were healthcare during the past month (Table I). When completed and returned (response rate 41%). examining the cohort of people who used primary Statistical analysis was conducted in two stages, healthcare versus those who did not, self-rated allowing for evaluation of a number of potential health status, age, income, region, and gender were utilization determinants, such as geographical re- identified as significant determinants of primary gion, gender, age, education, income, health insur- health services utilization. The results of the detailed ance coverage for primary and/or secondary care, logistic regression are presented in Table II. Indivi- self-rated health (5: very good; 4: good; 3: moderate; duals with very good self-rated health status were 2: poor; 1: very poor), and users’ and parents’ found to have a lower probability of visiting primary country of birth. Health insurance coverage refers health services compared to those with good, mod- to both public and private schemes, primary health- erate, poor, and very poor self-rated health status care utilization refers to visits to general practitioners (odds ratio [OR] 0.27B1). In addition, individuals and specialists, and secondary healthcare utilization who rated their health status as good had a lower refers to admissions to both private and public probability of visiting primary health services com- hospitals. pared to those with moderate, poor, and very poor We identified two main outcomes for the defini- self-rated health status (OR 0.52B1). tion of healthcare utilization: a) ‘‘any utilization The odds ratio (OR) of age was 1.01, indicating versus none’’ (yesno binary analysis) and b) fre- that older individuals have a higher probability of quency of primary healthcare consultations or hos- visiting primary health services than younger ones pitalization (‘‘number of visits or hospitalization’’). (OR 1.011). Individuals with a monthly income The frequency of utilization concerned those who range of t440880 had a higher probability of had received healthcare one or more times. Both visiting primary health services compared to those outcomes referred to the month right before the with an income range of t0440 (OR 1.51B1). completion of the questionnaire. Residents of the region of Epirus had a higher During the first stage of the statistical analysis, logistic regression was used in order to determine probability of visiting primary health services com- significant factors that affect the binary outcome pared to residents of the rest of the country (OR regarding health services utilization. During the 2.451). second stage of the statistical analysis, Poisson The odds ratio (OR) of gender was 1.251, regression was performed in order to determine indicating that women had a higher probability of 146 M. Geitona et al. Table I. Data concerning healthcare utilization. visiting primary health services than men (1: female 0: male). Primary Secondary As far as hospital care was concerned, 5.4% of the healthcare healthcare population reported having been admitted to hospi- utilization, % (n) utilization, % (n) tal in the past month (Table I). Self-rated health Region status and health insurance coverage for primary Eastern 49.09 (54/110) 6.36 (7/110) care were found to be significant determinants of Macedonia-Thraki hospitalization. The results of the detailed logistic Central Macedonia 49.31 (143/290) 4.48 (13/290) regression are presented in Table III. Regarding the Western Macedonia 56.82 (25/44) 4.55 (2/44) Epirus 66.67 (38/57) 8.77 (5/57) utilization of secondary care, individuals who rated Thessaly 45.58 (67/147) 4.08 (6/147) their health status as very good had a lower prob- Central Greece 55.56 (50/90) 6.67 (6/90) ability of hospitalization compared to individuals Western Greece 58.10 (61/105) 5.71 (6/105) with good, moderate, poor, and very poor self-rated Greater Athens 48.40 (288/595) 4.54 (27/595) health (OR 0.31B1). Similarly, individuals who Pelloponnese 47.06 (48/102) 6.86 (7/102) Crete 51.24 (62/121) 7.44 (9/121) rated their health status as good had a lower North Aegean Islands 41.18 (14/34) 2.94 (1/34) probability of hospitalization compared to indivi- South Aegean Islands 41.30 (19/46) 8.70 (4/46) duals with moderate, poor, and very poor self-rated Ionian Islands 60.87 (14/23) 9.09 (2/22) health (OR 0.22B1). Additionally, individuals with health insurance coverage for primary care had a Gender lower probability of hospitalization compared to Female 51.51 (358/695) 4.90 (34/694) individuals without insurance coverage for primary Male 49.06 (523/1066) 5.63 (60/1066) care (OR 0.58B1). When examining the cohort of people who used Age, years 1730 45.09 (78/173) 4.65 (8/172) primary healthcare during the past month, the 3145 40.82 (249/610) 3.77 (23/610) sample population exhibited an average of 2.51 4660 47.25 (241/510) 4.51 (23/510) outpatient visits per month (Table IV). The imple- 6175 65.56 (257/392) 8.16 (32/392) mentation of Poisson regression, examining the 76 72.97 (54/74) 10.81 (8/74) number of primary healthcare visits, showed that self-rated health greatly affects the frequency of Self-rated health primary healthcare utilization. The results of the Very good 30.71 (148/482) 2.70 (13/482) Good 51.09 (400/783) 2.94 (23/782) Poisson regression are presented in Table V. Accord- Moderate 67.37 (256/380) 11.58 (44/380) ing to the results, individuals who rated their health Poor 71.25 (57/80) 12.50 (10/80) status as very good had a higher probability of using Very poor 75 (12/16) 18.75 (3/16) primary healthcare less frequently than individuals who rated their health status as good, moderate, Education poor, and very poor (relative risk [RR] 0.72B1). Primary 57.11 (233/408) 8.09 (33/408) Similarly, individuals who rated their health status as Secondary 49.92 (309/619) 4.85 (30/618) Higher 45.71 (325/711) 4.08 (29/711) good had a higher probability of using primary healthcare less frequently compared to individuals Monthly income, t who rated their health status as moderate, poor, and 0440 56.97 (139/244) 9.43 (23/244) very poor (RR 0.63B1). Finally, individuals who 440.01880 55.04 (251/456) 5.49 (25/455) rated their health status as moderate had a higher 880.011467 49.19 (242/492) 4.27 (21/492) probability of using primary healthcare less fre- 1467.012347 48.33 (130/269) 4.09 (11/269) quently compared to individuals who rated their 2347.01 38.65 (63/163) 4.29 (7/163) health status as poor and very poor (RR 0.77B1). The study population exhibited an average of 1.52 Primary health insurance Yes 49.66 (720/1450) 4.76 (69/1449) admissions per month (Table IV). The implementa- No 52.53 (135/257) 8.56 (22/257) tion of the Poisson regression, examining the num- ber of hospitalizations, showed that self-rated health Secondary health insurance and geographical region greatly affect the frequency Yes 50.22 (812/1617) 5.07 (82/1616) of hospital care utilization. The results of the Poisson No 48.11 (51/106) 9.43 (10/106) regression are presented in Table VI. The relative risk (RR) of the Peloponnese region was 2.38, Total 50.06 (883/1764) 5.39 (95/1763) indicating that residents from this region had a Healthcare utilization in Greece 147 Table II. Logistic regression results for primary health services utilization. Variable Coefficient Odds ratio 95% CI p Self-rated health (very good vs. mean of the previous 1.27 0.27 0.210.36 B0.001 levels: good, moderate, poor, very poor) Self-rated health (good vs. mean of the previous levels: 0.64 0.52 0.400.68 B0.001 moderate, poor, very poor) Age 0.017 1.01 1.011.02 B0.001 Monthly income (t440.01880 vs. mean of the previous 0.41 1.51 1.082.11 0.014 level: t0440) Region (Epirus) 0.89 2.45 1.304.63 0.006 Gender (female) 0.22 1.25 1.011.55 0.042 Pearson goodness-of-fit test: p0.08. higher probability of having more hospital admis- tion. The frequency of hospitalization depends on sions compared to individuals from the rest of the region and lower health status. More specifically, the country (RR 2.381). Individuals who rated their region of Peloponnese presents a higher number of health status as poor also had a higher probability of hospital admissions. The results of our study are consistent with those being admitted to hospital (RR 2.391) than those of the international literature. Self-rated health with moderate, good, and very good health status. status, regardless of the type of service, is considered Finally, it is worth noting that the binary variables as the most important determinant of health services ‘‘users’ and parents’ country of birth’’ and ‘‘second- ary health insurance’’, as well as the numeric variable utilization in various studies (6,8,9,1921). The consideration that primary health services utilization ‘‘education’’, were found to be non-significant and should be based on health needs and also that it is were excluded from the final model. influenced by age and sex are common findings in numerous studies (10,11,2227). In addition, in- Discussion come is strongly associated with healthcare utiliza- According to our analysis, it appears that the tion and has been identified as one of the most utilization of primary healthcare in Greece depends significant determinants (1113,21). on self-rated health status, age, income, gender, and Further, our findings are similar to the results of region. Individuals with moderate or poor self-rated other studies that specifically refer to Greece. Two health status, older people, women, and residents of studies have found that income seems to be a the region of Epirus show increased utilization of determinant of utilization of health services in primary healthcare services. Income is a factor Greece. The results of both studies reveal that affecting the utilization of primary healthcare only income is related to the utilization of primary healthcare, low-income groups appear to have in- for individuals with lower income. The frequency of visits to primary healthcare is negatively correlated creased healthcare consumption, and higher-income with self-rated health status. groups seem to have better access to the provision of As far as hospital care is concerned, our results healthcare than lower-income groups (28,29). An- indicate that hospitalization is associated with self- other study found that low income, poor health rated health and insurance coverage for primary status, and educational level are factors associated healthcare. Individuals with better health status, as with higher use of primary healthcare services, while well as those who are covered by health insurance for insurance coverage for primary healthcare was also primary care, show decreased hospital care utiliza- correlated with higher use of hospital care (30). Table III. Logistic regression results for secondary health services utilization. Variable Coefficient Odds ratio 95% CI p Self-rated health (very good vs. mean of the previous levels: 1.15 0.31 0.170.57 B0.001 good, moderate, poor, very poor) Self-rated health (good vs. mean of the previous levels: 1.49 0.22 0.130.37 B0.001 moderate, poor, very poor) Health insurance coverage for primary care (yes) 0.53 0.58 0.350.97 0.042 Pearson goodness-of-fit test: p0.66. 148 M. Geitona et al. Table IV. Mean of healthcare utilization. tion of resources was found, indicating most varia- tions in Epirus, Peloponnese, Thessaly, and certain Primary Secondary islands (14,31,32). These findings are in accordance healthcare healthcare with our results, indicating increased healthcare utilization, u utilization, u ¯ ¯ utilization by the residents of the Epirus and Region Peloponnese regions. Eastern Macedonia-Thraki 2.81 1 In summary, the findings of our research indicate Central Macedonia 2.81 1.53 that self-rated health status seems to be the most Western Macedonia 2.2 1 important determinant in the utilization of both Epirus 2.55 1 Thessaly 2.19 1 primary and hospital care. Although various other Central Greece 2.84 1.33 demographic and socioeconomic factors such as Western Greece 2.11 1.16 income, gender, region, and age are associated with Greater Athens 2.29 1.44 reported utilization of primary healthcare, they did Pelloponnese 2.97 3.42 not appear to be as significant in hospital care. The Crete 2.40 2.11 North Aegean Islands 2.92 1 fact that income level was not identified to influence South Aegean Islands 3.63 1.25 hospital care could be due to the fact that income Ionian Islands 2.57 1 may be reflected by work-related social insurance coverage of the Greek population. However, the low Gender response rate concerning this particular question Female 2.50 1.44 inhibits us from deducing firm conclusions. Given Male 2.53 1.58 that income and insurance coverage are mostly work related, the finding that income is a determinant of Age, years 1730 2.46 1.87 primary healthcare utilization is empowered by the 3145 2.39 1.39 fact that insurance coverage for primary healthcare is 4660 2.42 1.69 also a determinant of the utilization of hospital care. 6175 2.58 1.5 Additionally, it was deduced that individuals who are 76 3.31 1.25 not covered by health insurance for primary care show increased hospitalization. This might be re- Self-rated health lated to the lack of a well-organized primary health- Very good 2.02 1.15 Good 2.03 1.56 care referral system, which could raise barriers to Moderate 3.01 1.27 hospitalization. Access to hospital care is free of Poor 4.82 3.3 charge, also giving patients the possibility to receive Very poor 3.5 1 laboratory and diagnostic tests for free during their stay. Education However, it should be mentioned that there are Primary 3.04 1.54 some limitations in our study. Due to the selection of Secondary 2.53 1.73 Higher 2.12 1.31 sampling units via a one- (by region) and not two- stage (by region and gender) stratified sampling Monthly income, t method, there are differences identified between 0440 3.13 1.34 the gender distribution of our sample and the general 440.01880 2.71 2.12 population. It would have been useful to take into 880.011467 2.16 1.23 consideration more socioeconomic and demographic 1467.012347 2.00 1.09 variables. However, the sample was selected from the 2347.01 2.61 1.85 national phone directory, and therefore multistage stratification was not possible. The fact that this was Primary health insurance Yes 2.46 1.57 a postal survey could explain the relatively low No 2.79 1.45 response rate compared to an interview-based sur- vey. Additionally, the statistically significant differ- Secondary health insurance ences found in our analysis between the utilization of Yes 2.44 1.59 primary and secondary healthcare in the regions of No 3.78 1.1 Epirus and Peloponnese, respectively, might have been more significant, or more associations might Total 2.51 1.52 have been found at a regional level, if the variables urban and rural had been taken into consideration. Additionally, in two other studies, the existence of Moreover, it is worth noting that healthcare provi- regional inequalities in both health and the alloca- sion in the country is structured and financed in a Healthcare utilization in Greece 149 Table V. Poisson regression results for the number of visits to primary health services. Variable Coefficient Relative risk 95% CI p Self-rated health (very good vs. mean of the previous levels: 0.32 0.72 0.630.83 B0.001 good, moderate, poor, very poor) Self-rated health (good vs. mean of the previous levels: 0.46 0.63 0.560.70 B0.001 moderate, poor, very poor) Self-rated health (moderate vs. mean of the previous levels: 0.25 0.77 0.660.90 0.001 poor, very poor) Pearson goodness-of-fit test: p0.06. Table VI. Poisson regression results for the frequency of hospital care utilization. Variable Coefficient Relative risk 95% CI p Self-rated health (poor vs. mean of the subsequent 0.87 2.39 1.613.54 B0.001 levels: moderate, good, very good) Region (Peloponnese) 0.86 2.38 1.533.70 B0.001 Pearson goodness-of-fit test: p0.99. 8. McGuire A, Henderson J, Mooney G. The economics of way that forces patients to use both public and health care. London: Routledge; 1988. p. 16781. private services concurrently (14), a fact that led us 9. Fylkesnes K. 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In conclusion, the findings of our research are 13. Newbold KB, Eyles J, Birch S. Equity in health care: encouraging, since they suggest that the utilization of methodological contributions to the analysis of hospital utilization within Canada. Soc Sci Med 1995;/40:/118192. health services in Greece is mostly determined by 14. Mossialos E, Allin S, Davaki K. Analysing the Greek health self-rated health status rather than other socioeco- system: a tale of fragmentation and inertia. Health Econ nomic factors. It is believed that similar studies 2005;/14:/S15168. should be conducted in order to improve both health 15. Zavras D, Geitona M, Kyriopoulos J. Paying more money for services planning and decision-making regarding better health care? Searching for willingness to accept to pay resource allocation. in Greece. In: Tavakoli M, Huw D. editors. Reforming health systems: analysis and evidence. Strategic issues in health care management. St. Andrews, Scotland: University of St. Andrews; 2005. p. 918. 16. OECD Health Data. Paris: OECD;2006 (www.ecosante.org/ References oecd.htm) 1. Feldstein PJ. Health care economics. New York: John Wiley; 17. Yfantopoulos J. Health inequalities  some of the issues and 1988. p. 76102. evidence from Greece. In: Ritsatakis A, Kyriopoulos J. 2. Grossmann M. The demand for health: a theoretical and editors. Neighbours in the Balkans: initiating a dialogue for empirical investigation. New York: National Bureau of health. Copenhagen: WHO; 1999. p. 10317. Economic Research; 1972. 18. Hosmer W, Lemeshow S. Applied logistic regression. 1st ed. 3. Newhouse JP, Marquis SE. The norms hypothesis and the New York: Wiley & Sons; 1989. demand for medical care. J Hum Resour 1978;/13:/15982. 19. Benzeval M, Judge K. The determinants of hospital utiliza- 4. Wagstaff A. The demand for health: some new empirical tion: implications for resource allocation in England. Health evidence. 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Determinants of healthcare utilization in Greece: Implications for decision-making

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Taylor & Francis
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Abstract

Objective: To explore factors influencing the utilization of primary and secondary healthcare in Greece. Methods: A national, geographically stratified sample was randomly selected. From November 2001 to March 2002, 5000 questionnaires were mailed, 4427 were actually received, and 1819 were completed and returned (response rate 41%). The questionnaire investigated respondents’ characteristics and their health services utilization. A number of potential utilization determinants were explored, such as region, gender, age, education, income, insurance coverage, number of family members, self-rated health status, country of birth, and parents’ country of birth. Results: The utilization of primary healthcare services depended on self-rated health status, age, income, gender, and region. Individuals with moderate and poor self-rated health, older people, women, and residents of the region of Epirus showed increased utilization of primary healthcare services. Income was a factor affecting the utilization of primary healthcare only at lower income levels. The frequency of visits for primary healthcare was negatively correlated with self-rated health status and increased as self-evaluation of health status worsened. Hospitalization was associated with self-rated health and insurance coverage for primary healthcare. Individuals with better self-rated health status, as well as those who were covered by health insurance for primary care, showed decreased hospital care utilization. The frequency of hospitalization depended on region and lower evaluations of health status. Conclusion: The findings of our research are encouraging, since they suggest that the utilization of health services in Greece is mostly determined by health status rather than other socioeconomic factors. It is believed that similar studies should be conducted in the country, since they can improve health service planning and reinforce decision-making towards healthcare resource allocation according to healthcare needs. Key words: Healthcare utilization determinants, health services utilization, primary healthcare, secondary healthcare Introduction The establishment of the NHS aimed at universal coverage of the Greek population and the reduction The health economics literature acknowledges var- of inequities in both the financing and access to ious factors that influence the utilization of health- healthcare, primarily through the widespread dis- care. Structural and organizational issues of the tribution of public primary healthcare facilities. healthcare sector, the existence of universal health More than two decades later, it seems that the coverage, as well as the type of health insurance are NHS has not yet achieved its initial goals. Greece factors that determine healthcare utilization. These, is among the OECD countries with the highest when combined with other socioeconomic, demo- healthcare spending as a percentage of gross domes- graphic, and epidemiological characteristics, are tic product (10% of GDP in 2006). Eighty-five per factors that significantly influence healthcare utiliza- cent of the Greek population is insured for primary tion (113). healthcare, 94% for hospitalization in the public The various socioeconomic, demographic, and sector, and approximately 8% has private health epidemiological changes that have taken place in insurance. Direct out-of-pocket and informal pay- Greece since the enactment of the NHS Law in 1983 ments are the highest in the European Union, have made the study of health services utilization a corresponding to 48% of total health expenditure, subject of major importance, especially at a time while payments from private health insurance ac- when healthcare reforms are being challenged. count only for about 2% (1417). Possible reasons Correspondence: Mary Geitona, Department of Economics, Korai 43 str., University of Thesally, Volos 38 333, Greece. Tel: 30 24210 74917/210 6211 591. E-mail: [email protected] (Accepted 15 June 2007) ISSN 1381-4788 print/ISSN 1751-1402 online # 2007 Taylor & Francis DOI: 10.1080/13814780701541340 Healthcare utilization in Greece 145 for the high private spending are the fragmentation significant factors that affect the number of visits in the provision of primary healthcare, the lack of (1) to healthcare providers. Both logistic and comprehensiveness in the social insurance coverage, Poisson regressions were performed by a step-wise limited access to healthcare provision, regional method. inequalities in resource allocation, and undersupply The independent variables that were included in of technological equipment in the public sector the model were the following: a) region (12 dummy (14,17). variables were created for 13 geographical regions), The objective of this study was to determine the b) gender (binary variable), c) country of birth factors that influence the utilization of primary and (binary variable, Greece versus elsewhere), d) coun- secondary healthcare in Greece. The results of the try of parents’ birth (binary variable, Greece versus study would contribute to the existing literature by elsewhere), e) age (numeric), f) education (nu- providing health policy decision-makers with in- meric), g) primary health insurance (binary vari- sights into how to manage both socioeconomic able), h) secondary health insurance (binary inequalities and health resources. variable), i) income (five-scale ordinal variable), and j) self-rated health (five-scale ordinal variable). In order to treat and compare the different Methods categories of the five-scale ordinal variables, Helmert A national, geographically stratified (one-stage coding was used. Finally, the Pearson chi-square method) sample of 5000 individuals was randomly goodness-of-fit test (18) was used to check the selected from the national phone directory. Self- models’ goodness of fit. administered questionnaires were sent during the period November 2001 to March 2002. The ques- Results tionnaires asked for information regarding respon- dents’ characteristics and their utilization of primary After two rounds of mailings, the response rate to the and secondary healthcare. Of the 5000 question- survey was 41%. According to the data collected, naires sent, 4427 were actually received due to 50% of the sample population utilized primary residence changes, deaths, etc.; 1819 of these were healthcare during the past month (Table I). When completed and returned (response rate 41%). examining the cohort of people who used primary Statistical analysis was conducted in two stages, healthcare versus those who did not, self-rated allowing for evaluation of a number of potential health status, age, income, region, and gender were utilization determinants, such as geographical re- identified as significant determinants of primary gion, gender, age, education, income, health insur- health services utilization. The results of the detailed ance coverage for primary and/or secondary care, logistic regression are presented in Table II. Indivi- self-rated health (5: very good; 4: good; 3: moderate; duals with very good self-rated health status were 2: poor; 1: very poor), and users’ and parents’ found to have a lower probability of visiting primary country of birth. Health insurance coverage refers health services compared to those with good, mod- to both public and private schemes, primary health- erate, poor, and very poor self-rated health status care utilization refers to visits to general practitioners (odds ratio [OR] 0.27B1). In addition, individuals and specialists, and secondary healthcare utilization who rated their health status as good had a lower refers to admissions to both private and public probability of visiting primary health services com- hospitals. pared to those with moderate, poor, and very poor We identified two main outcomes for the defini- self-rated health status (OR 0.52B1). tion of healthcare utilization: a) ‘‘any utilization The odds ratio (OR) of age was 1.01, indicating versus none’’ (yesno binary analysis) and b) fre- that older individuals have a higher probability of quency of primary healthcare consultations or hos- visiting primary health services than younger ones pitalization (‘‘number of visits or hospitalization’’). (OR 1.011). Individuals with a monthly income The frequency of utilization concerned those who range of t440880 had a higher probability of had received healthcare one or more times. Both visiting primary health services compared to those outcomes referred to the month right before the with an income range of t0440 (OR 1.51B1). completion of the questionnaire. Residents of the region of Epirus had a higher During the first stage of the statistical analysis, logistic regression was used in order to determine probability of visiting primary health services com- significant factors that affect the binary outcome pared to residents of the rest of the country (OR regarding health services utilization. During the 2.451). second stage of the statistical analysis, Poisson The odds ratio (OR) of gender was 1.251, regression was performed in order to determine indicating that women had a higher probability of 146 M. Geitona et al. Table I. Data concerning healthcare utilization. visiting primary health services than men (1: female 0: male). Primary Secondary As far as hospital care was concerned, 5.4% of the healthcare healthcare population reported having been admitted to hospi- utilization, % (n) utilization, % (n) tal in the past month (Table I). Self-rated health Region status and health insurance coverage for primary Eastern 49.09 (54/110) 6.36 (7/110) care were found to be significant determinants of Macedonia-Thraki hospitalization. The results of the detailed logistic Central Macedonia 49.31 (143/290) 4.48 (13/290) regression are presented in Table III. Regarding the Western Macedonia 56.82 (25/44) 4.55 (2/44) Epirus 66.67 (38/57) 8.77 (5/57) utilization of secondary care, individuals who rated Thessaly 45.58 (67/147) 4.08 (6/147) their health status as very good had a lower prob- Central Greece 55.56 (50/90) 6.67 (6/90) ability of hospitalization compared to individuals Western Greece 58.10 (61/105) 5.71 (6/105) with good, moderate, poor, and very poor self-rated Greater Athens 48.40 (288/595) 4.54 (27/595) health (OR 0.31B1). Similarly, individuals who Pelloponnese 47.06 (48/102) 6.86 (7/102) Crete 51.24 (62/121) 7.44 (9/121) rated their health status as good had a lower North Aegean Islands 41.18 (14/34) 2.94 (1/34) probability of hospitalization compared to indivi- South Aegean Islands 41.30 (19/46) 8.70 (4/46) duals with moderate, poor, and very poor self-rated Ionian Islands 60.87 (14/23) 9.09 (2/22) health (OR 0.22B1). Additionally, individuals with health insurance coverage for primary care had a Gender lower probability of hospitalization compared to Female 51.51 (358/695) 4.90 (34/694) individuals without insurance coverage for primary Male 49.06 (523/1066) 5.63 (60/1066) care (OR 0.58B1). When examining the cohort of people who used Age, years 1730 45.09 (78/173) 4.65 (8/172) primary healthcare during the past month, the 3145 40.82 (249/610) 3.77 (23/610) sample population exhibited an average of 2.51 4660 47.25 (241/510) 4.51 (23/510) outpatient visits per month (Table IV). The imple- 6175 65.56 (257/392) 8.16 (32/392) mentation of Poisson regression, examining the 76 72.97 (54/74) 10.81 (8/74) number of primary healthcare visits, showed that self-rated health greatly affects the frequency of Self-rated health primary healthcare utilization. The results of the Very good 30.71 (148/482) 2.70 (13/482) Good 51.09 (400/783) 2.94 (23/782) Poisson regression are presented in Table V. Accord- Moderate 67.37 (256/380) 11.58 (44/380) ing to the results, individuals who rated their health Poor 71.25 (57/80) 12.50 (10/80) status as very good had a higher probability of using Very poor 75 (12/16) 18.75 (3/16) primary healthcare less frequently than individuals who rated their health status as good, moderate, Education poor, and very poor (relative risk [RR] 0.72B1). Primary 57.11 (233/408) 8.09 (33/408) Similarly, individuals who rated their health status as Secondary 49.92 (309/619) 4.85 (30/618) Higher 45.71 (325/711) 4.08 (29/711) good had a higher probability of using primary healthcare less frequently compared to individuals Monthly income, t who rated their health status as moderate, poor, and 0440 56.97 (139/244) 9.43 (23/244) very poor (RR 0.63B1). Finally, individuals who 440.01880 55.04 (251/456) 5.49 (25/455) rated their health status as moderate had a higher 880.011467 49.19 (242/492) 4.27 (21/492) probability of using primary healthcare less fre- 1467.012347 48.33 (130/269) 4.09 (11/269) quently compared to individuals who rated their 2347.01 38.65 (63/163) 4.29 (7/163) health status as poor and very poor (RR 0.77B1). The study population exhibited an average of 1.52 Primary health insurance Yes 49.66 (720/1450) 4.76 (69/1449) admissions per month (Table IV). The implementa- No 52.53 (135/257) 8.56 (22/257) tion of the Poisson regression, examining the num- ber of hospitalizations, showed that self-rated health Secondary health insurance and geographical region greatly affect the frequency Yes 50.22 (812/1617) 5.07 (82/1616) of hospital care utilization. The results of the Poisson No 48.11 (51/106) 9.43 (10/106) regression are presented in Table VI. The relative risk (RR) of the Peloponnese region was 2.38, Total 50.06 (883/1764) 5.39 (95/1763) indicating that residents from this region had a Healthcare utilization in Greece 147 Table II. Logistic regression results for primary health services utilization. Variable Coefficient Odds ratio 95% CI p Self-rated health (very good vs. mean of the previous 1.27 0.27 0.210.36 B0.001 levels: good, moderate, poor, very poor) Self-rated health (good vs. mean of the previous levels: 0.64 0.52 0.400.68 B0.001 moderate, poor, very poor) Age 0.017 1.01 1.011.02 B0.001 Monthly income (t440.01880 vs. mean of the previous 0.41 1.51 1.082.11 0.014 level: t0440) Region (Epirus) 0.89 2.45 1.304.63 0.006 Gender (female) 0.22 1.25 1.011.55 0.042 Pearson goodness-of-fit test: p0.08. higher probability of having more hospital admis- tion. The frequency of hospitalization depends on sions compared to individuals from the rest of the region and lower health status. More specifically, the country (RR 2.381). Individuals who rated their region of Peloponnese presents a higher number of health status as poor also had a higher probability of hospital admissions. The results of our study are consistent with those being admitted to hospital (RR 2.391) than those of the international literature. Self-rated health with moderate, good, and very good health status. status, regardless of the type of service, is considered Finally, it is worth noting that the binary variables as the most important determinant of health services ‘‘users’ and parents’ country of birth’’ and ‘‘second- ary health insurance’’, as well as the numeric variable utilization in various studies (6,8,9,1921). The consideration that primary health services utilization ‘‘education’’, were found to be non-significant and should be based on health needs and also that it is were excluded from the final model. influenced by age and sex are common findings in numerous studies (10,11,2227). In addition, in- Discussion come is strongly associated with healthcare utiliza- According to our analysis, it appears that the tion and has been identified as one of the most utilization of primary healthcare in Greece depends significant determinants (1113,21). on self-rated health status, age, income, gender, and Further, our findings are similar to the results of region. Individuals with moderate or poor self-rated other studies that specifically refer to Greece. Two health status, older people, women, and residents of studies have found that income seems to be a the region of Epirus show increased utilization of determinant of utilization of health services in primary healthcare services. Income is a factor Greece. The results of both studies reveal that affecting the utilization of primary healthcare only income is related to the utilization of primary healthcare, low-income groups appear to have in- for individuals with lower income. The frequency of visits to primary healthcare is negatively correlated creased healthcare consumption, and higher-income with self-rated health status. groups seem to have better access to the provision of As far as hospital care is concerned, our results healthcare than lower-income groups (28,29). An- indicate that hospitalization is associated with self- other study found that low income, poor health rated health and insurance coverage for primary status, and educational level are factors associated healthcare. Individuals with better health status, as with higher use of primary healthcare services, while well as those who are covered by health insurance for insurance coverage for primary healthcare was also primary care, show decreased hospital care utiliza- correlated with higher use of hospital care (30). Table III. Logistic regression results for secondary health services utilization. Variable Coefficient Odds ratio 95% CI p Self-rated health (very good vs. mean of the previous levels: 1.15 0.31 0.170.57 B0.001 good, moderate, poor, very poor) Self-rated health (good vs. mean of the previous levels: 1.49 0.22 0.130.37 B0.001 moderate, poor, very poor) Health insurance coverage for primary care (yes) 0.53 0.58 0.350.97 0.042 Pearson goodness-of-fit test: p0.66. 148 M. Geitona et al. Table IV. Mean of healthcare utilization. tion of resources was found, indicating most varia- tions in Epirus, Peloponnese, Thessaly, and certain Primary Secondary islands (14,31,32). These findings are in accordance healthcare healthcare with our results, indicating increased healthcare utilization, u utilization, u ¯ ¯ utilization by the residents of the Epirus and Region Peloponnese regions. Eastern Macedonia-Thraki 2.81 1 In summary, the findings of our research indicate Central Macedonia 2.81 1.53 that self-rated health status seems to be the most Western Macedonia 2.2 1 important determinant in the utilization of both Epirus 2.55 1 Thessaly 2.19 1 primary and hospital care. Although various other Central Greece 2.84 1.33 demographic and socioeconomic factors such as Western Greece 2.11 1.16 income, gender, region, and age are associated with Greater Athens 2.29 1.44 reported utilization of primary healthcare, they did Pelloponnese 2.97 3.42 not appear to be as significant in hospital care. The Crete 2.40 2.11 North Aegean Islands 2.92 1 fact that income level was not identified to influence South Aegean Islands 3.63 1.25 hospital care could be due to the fact that income Ionian Islands 2.57 1 may be reflected by work-related social insurance coverage of the Greek population. However, the low Gender response rate concerning this particular question Female 2.50 1.44 inhibits us from deducing firm conclusions. Given Male 2.53 1.58 that income and insurance coverage are mostly work related, the finding that income is a determinant of Age, years 1730 2.46 1.87 primary healthcare utilization is empowered by the 3145 2.39 1.39 fact that insurance coverage for primary healthcare is 4660 2.42 1.69 also a determinant of the utilization of hospital care. 6175 2.58 1.5 Additionally, it was deduced that individuals who are 76 3.31 1.25 not covered by health insurance for primary care show increased hospitalization. This might be re- Self-rated health lated to the lack of a well-organized primary health- Very good 2.02 1.15 Good 2.03 1.56 care referral system, which could raise barriers to Moderate 3.01 1.27 hospitalization. Access to hospital care is free of Poor 4.82 3.3 charge, also giving patients the possibility to receive Very poor 3.5 1 laboratory and diagnostic tests for free during their stay. Education However, it should be mentioned that there are Primary 3.04 1.54 some limitations in our study. Due to the selection of Secondary 2.53 1.73 Higher 2.12 1.31 sampling units via a one- (by region) and not two- stage (by region and gender) stratified sampling Monthly income, t method, there are differences identified between 0440 3.13 1.34 the gender distribution of our sample and the general 440.01880 2.71 2.12 population. It would have been useful to take into 880.011467 2.16 1.23 consideration more socioeconomic and demographic 1467.012347 2.00 1.09 variables. However, the sample was selected from the 2347.01 2.61 1.85 national phone directory, and therefore multistage stratification was not possible. The fact that this was Primary health insurance Yes 2.46 1.57 a postal survey could explain the relatively low No 2.79 1.45 response rate compared to an interview-based sur- vey. Additionally, the statistically significant differ- Secondary health insurance ences found in our analysis between the utilization of Yes 2.44 1.59 primary and secondary healthcare in the regions of No 3.78 1.1 Epirus and Peloponnese, respectively, might have been more significant, or more associations might Total 2.51 1.52 have been found at a regional level, if the variables urban and rural had been taken into consideration. Additionally, in two other studies, the existence of Moreover, it is worth noting that healthcare provi- regional inequalities in both health and the alloca- sion in the country is structured and financed in a Healthcare utilization in Greece 149 Table V. Poisson regression results for the number of visits to primary health services. Variable Coefficient Relative risk 95% CI p Self-rated health (very good vs. mean of the previous levels: 0.32 0.72 0.630.83 B0.001 good, moderate, poor, very poor) Self-rated health (good vs. mean of the previous levels: 0.46 0.63 0.560.70 B0.001 moderate, poor, very poor) Self-rated health (moderate vs. mean of the previous levels: 0.25 0.77 0.660.90 0.001 poor, very poor) Pearson goodness-of-fit test: p0.06. Table VI. Poisson regression results for the frequency of hospital care utilization. Variable Coefficient Relative risk 95% CI p Self-rated health (poor vs. mean of the subsequent 0.87 2.39 1.613.54 B0.001 levels: moderate, good, very good) Region (Peloponnese) 0.86 2.38 1.533.70 B0.001 Pearson goodness-of-fit test: p0.99. 8. McGuire A, Henderson J, Mooney G. The economics of way that forces patients to use both public and health care. London: Routledge; 1988. p. 16781. private services concurrently (14), a fact that led us 9. Fylkesnes K. 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Journal

European Journal of General Practice – Taylor & Francis

Published: Jan 1, 2007

Keywords: Healthcare utilization determinants; health services utilization; primary healthcare; secondary healthcare

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