Disparities in access to health care in three French regions.
OBJECTIVE
This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d'Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.


METHODS
To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age-adjusted hospital discharge rates for revascularization - bypass surgery and angioplasty - among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization.


RESULTS
In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.


CONCLUSIONS
Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.
The Hastings Center, United States. Electronic address: gusmanom@thehastingscenter.org.
Michael K
MK
Gusmano
International Longevity Center-USA, Columbia University, United States.
Daniel
D
Weisz
Wagner School of Public Service, New York University, United States.
Victor G
VG
Rodwin
Columbia University, United States.
Jonas
J
Lang
Division of Biostatistics, Department of Population Health, New York University, United States.
Meng
M
Qian
ORS PACA, Southeastern Regional Health Observatory, Marseille, France; INSERM, U912 "Economic & Social Sciences, Health Systems & Societies" (SE4S), Marseille, France; Université Aix Marseille, IRD, UMR-S912, Marseille, France.
Aurelie
A
Bocquier
French National Health Insurance Fund (CNAMTS), France.
Veronique
V
Moysan
ORS PACA, Southeastern Regional Health Observatory, Marseille, France; INSERM, U912 "Economic & Social Sciences, Health Systems & Societies" (SE4S), Marseille, France; Université Aix Marseille, IRD, UMR-S912, Marseille, France.
Pierre
P
Verger
D000367:Age Factors; D000553:Ambulatory Care / Q000706:statistics & numerical data; D005260:Female; D005602:France / Q000453:epidemiology; D062306:Geography, Medical; D006291:Health Policy; D006297:Health Services Accessibility / Q000592:standards / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000592:standards / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008511:Medicine / Q000592:standards / Q000706:statistics & numerical data; D010297:Paris / Q000453:epidemiology; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000706:statistics & numerical data; D012737:Sex Factors
Access to care; Equity; France