title: Socioeconomic inequality in hip replacement in four European countries from 2002 to 2009--area-level analysis of hospital data.
abstract: BACKGROUND
  Cross-country comparisons of socioeconomic equity in health care typically use sample survey data on general services such as physician visits. This study uses comprehensive administrative data on a specific service: hip replacement.
  
  
  METHODS
  We analyse 651 652 publicly funded hip replacements, excluding fractures and accidents, in adults over 35 in Denmark, England, Portugal and Spain from 2002 to 2009. Sub-national administrative areas are split into socioeconomic quintile groups comprising approximately one-fifth of the national population. Area-level Poisson regression with Huber-White standard errors is used to calculate age-sex standardised hip replacement rates by quintile group, together with gaps and ratios between richest and poorest groups (Q5 and Q1) and the middle group (Q3).
  
  
  RESULTS
  We find pro-rich-area inequality in England (2009 Q5/Q1 ratio 1.35 [CI 1.25-1.45]) and Spain (2009 Q5/Q1 ratio 1.43 [CI 1.17-1.70]), pro-poor-area inequality in Portugal (2009 Q5/Q1 ratio 0.67 [CI 0.50-0.83]) and no significant inequality in Denmark. Pro-rich-area inequality increased over time in England and Spain but not significantly. Within-country differences between socioeconomic quintile groups are smaller than between-country differences in general population averages: hip replacement rates are substantially lower in Portugal and Spain (8.6 and 7.4 per 10 000 in 2009) than England and Denmark (20.2 and 27.8 per 10 000 in 2009).
  
  
  CONCLUSIONS
  Despite limitations regarding individual-level inequality and area heterogeneity, analysis of area-level data on publicly funded hospital activity can provide useful cross-country comparisons and longitudinal monitoring of socioeconomic inequality in specific health services. Although this kind of analysis cannot provide definitive answers, it can raise important questions for decision makers.
authors.affiliation: 1 Centre for Health Economics, University of York, York, UK richard.cookson@york.ac.uk.
authors.forename: Richard
authors.initials: R
authors.lastname: Cookson
authors.affiliation: 1 Centre for Health Economics, University of York, York, UK.
authors.forename: Nils
authors.initials: N
authors.lastname: Gutacker
authors.affiliation: 2 Institute for Health Sciences in Aragon (IIS Aragon), Zaragoza, Spain 3 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Sandra
authors.initials: S
authors.lastname: Garcia-Armesto
authors.affiliation: 2 Institute for Health Sciences in Aragon (IIS Aragon), Zaragoza, Spain 3 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Ester
authors.initials: E
authors.lastname: Angulo-Pueyo
authors.affiliation: 4 Centre of Health Economics Research, University of Southern Denmark, Odense, Denmark.
authors.forename: Terkel
authors.initials: T
authors.lastname: Christiansen
authors.affiliation: 5 Department of Health Sciences, University of York, UK.
authors.forename: Karen
authors.initials: K
authors.lastname: Bloor
authors.affiliation: 2 Institute for Health Sciences in Aragon (IIS Aragon), Zaragoza, Spain 3 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Bernal-Delgado
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D003718:Denmark; D004739:England; D005260:Female; D054624:Health Status Disparities; D054625:Healthcare Disparities; D006779:Hospitals, Public / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011174:Portugal; D017062:Small-Area Analysis; D012923:Social Class; D013030:Spain