Unjustified variation in the use of healthcare services

About the Project

The overarching theme of this dissertation was geographic and socioeconomic variation in the consumption of specialist healthcare services. Three different types of healthcare services were studied in the dissertation. The analyses utilized complete population data at the individual level, with a high degree of completeness and quality, from national registers (Norwegian Patient Register, Cancer Registry, and Statistics Norway).

Research Questions

The main objectives of the dissertation were to:

1. explore geographic variation in the consumption of three different healthcare services in Norway
2. explore socioeconomic variation in the consumption of three different healthcare services in Norway
3. investigate whether geographic variation in the consumption of these healthcare services could be explained by differences in socioeconomic status

In Article I, hospital admissions for children aged 1-16 years were studied. In Article II, cancer care pathways for lung, colorectal, prostate, and breast cancer were examined, focusing on two different populations; i) the proportion of pathway patients who did not have the relevant cancer type, and ii) the proportion of cancer patients included in the care pathways. In Article III, patients with atrial fibrillation and the proportion treated with ablation were studied.

Significant geographic and socioeconomic variation was found, and the geographic variation could not be explained by differences in socioeconomic status between the geographic areas. Children with parents with low educational levels were most likely to be admitted and had the highest number of admissions per child, while also having the least severe admissions. Cancer patients in the highest income group were most likely to be included in care pathways, while no systematic differences were found between income and education groups for the proportion of pathway patients who did not have the relevant cancer type. Atrial fibrillation patients with higher education and/or higher income were more often treated with ablation, and the effect of education was stronger with increasing age.

The variation documented in this dissertation challenges the perception that healthcare provision and medical practice in Norway are rational and evidence-based. Capacity differences may likely explain parts of the geographic variation, and differences in needs may likely explain some of the socioeconomic variation. To understand the causes of variation, one must also study what underlies clinical decisions, i.e., both patients' and doctors' preferences, as well as local traditions and clinical practices.