Geographic and socioeconomic variation in the utilisation of specialist health care services in Norway – Three selected health care services

The overall theme of this thesis is geographic and socioeconomic variation in the use of specialist health care services. Three different health care services were studied. Complete population data on individual level with high level of quality from nationwide registries (i.e., The Norwegian Patient Registry, The Cancer Registry of Norway and Statistics Norway) were used in the analysis. The main aims of the thesis were to: 1) explore geographic variation in the use of three different health care services in Norway, 2) explore socioeconomic variation in the use of three different health care services in Norway, and 3) investigate whether geographic variation in the use of these health care services can be explained by differences in socioeconomic status. In paper I, hospital admissions for children aged 1-16 years were studied. In paper II, cancer patient pathways (CPP) for lung, colorectal, prostate or breast cancer were studied, and the focus was on two different proportions; i) the proportion of patients in cancer patients pathways who do not have the relevant cancer, and ii) the proportion of cancer patients included in cancer patient pathways. In paper III patients with atrial fibrillation and the proportion treated with ablation were studied. Substantial geographic and socioeconomic variation was documented, and possible differences in socioeconomic status could not explain the geographic variation. Children of parents with low educational level had the highest admission probability, the highest number of admissions, but the reason for the admission tended to be less severe. Cancer patients in high income groups had the highest probability of being included in cancer patient pathways, while for the patients included in the cancer patient pathways, no systematic differences in the proportion of patients who do not have the relevant cancer were found with income and education groups. Atrial fibrillation patients with high level of education and high income were more frequently treated with ablation, and the education effect increased with increasing age. The variation documented in this thesis challenges the idea that the distribution of medical practice and care in Norway is rational and evidence-based. Differences in capacity can probably explain some of the geographic variation, and differences in need might explain some of the socioeconomic variation. However, in search of explanations one must also study the impact of personal beliefs in both patients and physicians, local traditions, and clinical practice