George A Kaplan, Elsie R Pamuk, John W Lynch, Richard D Cohen, Jennifer L Balfour
Abstract
Objective - To examine the relation between health outcomes and the equality with which income is distributed in the United States.
Design - The degree of income inequality, defined as the percentage of total household income received by the less well off 50% of households, and changes in income inequality were calculated for the 50 states in 1980 and 1990, These measures were then examined in relation to all cause mortality adjusted for age for each state, age specific deaths, changes in mortalities, and other health outcomes and potential pathways for 1980, 1990, and 1989-91.
Main outcome measure - Age adjusted mortality from all causes.
Results - There was a significant correlation (r=0.62, P less than 0.001) between the percentage of total household income received by the less well off 50% in each state and all cause mortality, unaffected by adjustment for state median incomes. Income inequality was also significantly associated with age specific mortalities and rates of low birth weight, homicide, violent crime, work disability, expenditures on medical care and police protection, smoking, and sedentary activity. Rates of unemployment, imprisonment, recipients of income assistance and food stamps, lack of medical insurance, and educational outcomes were also worse as income inequality increased. Income inequality was also associated with mortality trends, and there was a suggestion of an impact of inequality trends on mortality trends.
Conclusions - Variations between states In the inequality of the distribution of income are significantly associated with variations between states in a large number of health outcomes and social indicators and with mortality trends. These differences parallel relative investments in human and social capital. Economic policies that influence income and wealth inequality may have an important impact on the health of countries. Human Population Laboratory California Department of Health Services Berkeley CA 94704 USA George A Kaplan chief John W Lynch research associate Richard D Cohen senior research associate Jennifer L Balfour graduate assistant
National Center for Health Statistics Centers for Disease Control and Prevention Hyattsville MD 20782 USA Elsie R Pamuk health statistician
Correspondence to: Dr Kaplan.
Bruce P Kennedy, Ichiro Kawachi, Deborah Prothrow-Stith
Abstract
Objective - To determine the effect of income inequality as measured by the Robin Hood index and the Gini coefficient on all cause and cause specific mortality in the United States.
Design - Cross sectional ecological study.
Setting - Households in the United States.
Main outcome measures - Disease specific mortality, income, household size, poverty, and smoking rates for each state.
Results - The Robin Hood index was positively correlated with total mortality adjusted for age (r=0.54; P less than 0.05). This association remained after adjustment for poverty (P less than 0.007), where each percentage increase in the index was associated with an increase in the total mortality of 21.68 deaths per 100,000. Effects of the index were also found for infant mortality (P=0.013); coronary heart disease (P=0.004); malignant neoplasms (P=0.023); and homicide (P less than 0.001). Strong associations were also found between the index and causes of death amenable to medical intervention. The Gini coefficient showed very little correlation with any of the causes of death.
Conclusion - Variations between states in the inequality of income were associated with increased mortality from several causes. The size of the gap between the wealthy and the less well off - as distinct from the absolute standard of living enjoyed by the poor - seems to matter in its own right. The findings suggest that policies that deal with the growing inequities in income distribution may have an important impact on the health of the population.
Department of Health Policy and Management Harvard School of Public Health Boston MA 02115 USA Bruce P Kennedy instructor Deborah Prothrow-Stith professor
Department of Health and Social Behavior Harvard School of Public Health Boston Ichiro Kawachi assistant professor
Correspondence to: Dr Kennedy.
Roy A Carr-Hill, Nigel Rice, Martin Roland
Abstract
Objective - To identify the socioeconomic determinants of consultation rates in general practice.
Design - Analysis of data from the fourth national morbidity survey of general practices (MSGP4) including sociodemographic details of individual patients and small area statistics from the 1991 census. Multilevel modelling techniques were used to take account of both individual patient data and small area statistics to relate socioeconomic and health status factors directly to a measure of general practitioner workload.
Results - Higher rates of consultations were found in patients who were classified as permanently sick, unemployed (especially those who became unemployed during the study year), living in rented accommodation, from the Indian subcontinent, living with a spouse or partner (women only), children living with two parents (girls only), and living in urban areas, especially those living relatively near the practice. When characteristics of individual patients are known and controlled for the role of "indices of deprivation" is considerably reduced. The effect of individual sociodemographic characteristics were shown to vary between different areas.
Conclusions - Demographic and socioeconomic factors can act as powerful predictors of consultation patterns. Though it will always be necessary to retain some local planning discretion, the sets of coefficients estimated for individual level factors, area level characteristics, and for practice groupings may be sufficient to provide an indicative level of demand for general medical services. Although the problems in using socioeconomic data from individual patients would be substantial, these results are relevant to the development of a resource allocation formula for general practice.
Centre for Health Economics University of York York YO1 5DD Roy A Carr-HilI senior research fellow Nigel Rice research fellow
National Primary Care Research and Development Centre University of Manchester Manchester M13 9PL Martin Roland director of research and development
Correspondence to: Dr Rice.
Charlotte Paterson
Abstract
Objective - To assess the sensitivity to within person change over time of an outcome measure for practitioners in primary care that is applicable to a wide range of illness.
Design - Comparison of a new patient generated instrument, the measure yourself medical outcome profile (MYMOP), with the SF-36 health profile and a five point change score; all scales were completed during the consultation with practitioners and repeated after four weeks. 103 patients were followed up for 16 weeks and their results charted; seven practitioners were interviewed.
Setting - Established practice of the four NHS general practitioners and four of the private complementary practitioners working in one medical centre.
Subjects - Systematic sample of 218 patients from general practice and all 47 patients of complementary practitioners; patients had had symptoms for more than seven days.
Outcome measure - Standardised response mean and index of responsiveness; views of practitioners.
Results - The index of responsiveness, relating to the minimal clinically important difference, was high for MYMOP: 1.14 for the first symptom, 1.33 for activity, and 0.85 for the profile compared with less than 0.45 for SF-36. MYMOP's validity was supported by significant correlation between the change score and the change in the MYMOP score and the ability of this instrument to detect more improvement in acute than in chronic conditions. Practitioners found that MYMOP was practical and applicable to all patients with symptoms and that its use increased their awareness of patients' priorities.
Conclusion - MYMOP shows promise as an outcome measure for primary care and for complementary treatment. It is more sensitive to change than the SF-36 and has the added bonus of improving patient-practitioner communication.
Warwick House Medical Centre Taunton Somerset TA1 2YJ Charlotte Paterson general practitioner