title: Socioeconomic differences in mortality amenable to health care among Finnish adults 1992-2003: 12 year follow up using individual level linked population register data.
abstract: BACKGROUND
  Finland decentralised its universal healthcare system and introduced market reforms in the 1990s. Despite a commitment to equity, previous studies have identified persistent socio-economic inequities in healthcare, with patterns of service use that are more pro-rich than in most other European countries. To examine whether similar socio-economic patterning existed for mortality amenable to intervention in primary or specialist care, we investigated trends in amenable mortality by income group from 1992-2003.
  
  
  METHODS
  We analysed trends in all cause, total disease and mortality amenable to health care using individual level data from the National Causes of Death Register for those aged 25 to 74 years in 1992-2003. These data were linked to sociodemographic data for 1990-2002 from population registers using unique personal identifiers. We examined trends in causes of death amenable to intervention in primary or specialist healthcare by income quintiles.
  
  
  RESULTS
  Between 1992 and 2003, amenable mortality fell from 93 to 64 per 100,000 in men and 74 to 54 per 100,000 in women, an average annual decrease in amenable mortality of 3.6% and 3.1% respectively. Over this period, all cause mortality declined less, by 2.8% in men and 2.5% in women. By 2002-2003, amenable mortality among men in the highest income group had halved, but the socioeconomic gradient had increased as amenable mortality reduced at a significantly slower rate for men and women in the lowest income quintile. Compared to men and women in the highest income quintile, the risk ratio for mortality amenable to primary care had increased to 14.0 and 20.5 respectively, and to 8.8 and 9.36 for mortality amenable to specialist care.
  
  
  CONCLUSIONS
  Our findings demonstrate an increasing socioeconomic gradient in mortality amenable to intervention in primary and specialist care. This is consistent with the existing evidence of inequity in healthcare use in Finland and provides supporting evidence of changes in the socioeconomic gradient in health service use and in important outcomes. The potential adverse effect of healthcare reform on timely access to effective care for people on low incomes provides a plausible explanation that deserves further attention.
authors.affiliation: Directorate of Public Health and Health Policy, NHS Lothian, Waverley Gate, 2-4 Waterloo Place, Edinburgh EH1 3EG, Scotland. alison.mccallum@nhslothian.scot.nhs.uk
authors.forename: Alison K
authors.initials: AK
authors.lastname: McCallum
authors.forename: Kristiina
authors.initials: K
authors.lastname: Manderbacka
authors.forename: Martti
authors.initials: M
authors.lastname: Arffman
authors.forename: Alastair H
authors.initials: AH
authors.lastname: Leyland
authors.forename: Ilmo
authors.initials: I
authors.lastname: Keskimäki
mesh_terms: D000328:Adult; D000368:Aged; D002423:Cause of Death / Q000639:trends; D005260:Female; D005387:Finland / Q000453:epidemiology; D005500:Follow-Up Studies; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008498:Medical Record Linkage; D008875:Middle Aged; D009026:Mortality / Q000639:trends*; D012042:Registries; D012923:Social Class