Equity in the use of publicly subsidized psychotherapy among elderly Danish cancer patients – a register-based cohort study

Figures & data

Figure 1. The Behavioral Model of Health Service Use. Based on Andersen (1995) [12].

Table I. Descriptive characteristics of study population and of psychotherapy users.

	All cancer patients* (n = 3646)		Users of psychotherapy (n = 83)
	n	%	n	%
Age at diagnosis (years)
< 60	151	4.1	10	12
60–64	917	25.2	31	37.3
65–69	1293	35.5	32	38.6
70–74	1003	27.5	9	10.8
> 74	282	7.7	1	1.2
Gender
Female	1708	46.8	52	62.7
Male	1938	53.2	31	37.3
Length of education (years)
< 8	1168	32	18	21.7
8–10	1696	46.5	39	47
> 10	782	21.4	26	31.3
Cancer site
Prostate	709	19.4	9	10.8
Breast	658	18	24	28.9
Colorectal	422	11.6	7	8.4
Lung	381	10.4	11	13.3
Urinary tract	297	8.1	3	3.6
Other digestive organs	281	7.7	6	7.2
Leukemias and lymphomas	249	6.8	6	7.2
Gynecological	167	4.6	2	2.4
Other	160	4.4	8	9.6
Malignant melanoma	151	4.1	1	1.2
Head and neck	94	2.6	1	1.2
Central nervous system	77	2.1	5	6
Charlson comorbidity index
0	3379	92.7	79	95.2
≥ 1	267	7.3	4	4.8
SF-36 mental component summary mean (range)	54.34 (10.61–72.02)		49.11 (13.16–64.56)
SF-36 physical component summary mean (range)	51.40 (10.28–66.16)		51.72 (27.42–64.10)
Reliable emotional support from partner
No partner	694	19	17	20.5
Partner, no reliable support	169	4.6	11	13.3
Partner, reliable support	2783	76.3	55	66.3
Reliable emotional support from children
No children	350	9.6	10	12
Children, no reliable support	426	11.7	9	10.8
Children, reliable support	2870	78.7	64	77.1
Reliable emotional support from family members other than partner and children
No other family members	78	2.1	2	2.4
Other family members, no reliable support	1218	33.4	34	41
Other family members, reliable support	2350	64.5	47	56.6
Previous psychotherapy use
Yes	75	2.1	8	9.6
No	3571	97.9	75	90.4
Days from cancer diagnosis to first psychotherapy session mean (range)
			180.9 (9–545) (median: 139)
Number of psychotherapy sessions attended mean (range)			4.6 (1–12)† (median: 4)

Some percentages may not add up to 100 because of rounding.

*Patients in the Diet, Cancer and Health cohort with a first cancer diagnosed after 2002; †14 patients died within 12 months of their last session, and their treatment course might hence not have been completed had they not died. After exclusion of these patients, the mean number of sessions attended is slightly higher (4.9), while the median remains 4.

Table II. Hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) for psychotherapy use by 3646 patients within 18 months of first cancer diagnosis after 2002.

	Crude analyses HR [95% CI]	Predisposing factors^1 HR [95% CI]	Predisposing & enabling factors^2 HR [95% CI]	Predisposing, enabling & need factors^3 HR [95% CI]
Predisposing factors
Age at diagnosis (years)
< 60	Reference	Reference	Reference	Reference
60–64	0.50 [0.25, 1.02] ˙	0.51 [0.25, 1.04] ˙	0.50 [0.25, 1.03] ˙	0.54 [0.26, 1.11] ˙
65–69	0.37 [0.18, 0.75] **	0.41 [0.20, 0.83] *	0.39 [0.19, 0.80] **	0.43 [0.21, 0.89] *
70–74	0.14 [0.06, 0.34] ***	0.16 [0.07, 0.40] ***	0.16 [0.06, 0.39] ***	0.17 [0.07, 0.41] ***
> 74	0.06 [0.01, 0.44] **	0.07 [0.01, 0.51] **	0.06 [0.01, 0.50] **	0.07 [0.01, 0.57] *
Gender
Female	Reference	Reference	Reference	Reference
Male	0.53 [0.34, 0.83] **	0.58 [0.37, 0.92] **	0.64 [0.40, 1.02] *	0.68 [0.42, 1.10] *
Length of education (years)
< 8	Reference	Reference	Reference	Reference
8–10	1.44 [0.82, 2.52]	1.19 [0.68, 2.09]	1.19 [0.67, 2.09]	1.23 [0.69, 2.17]
> 10	2.06 [1.13, 3.76] **	1.74 [0.95, 3.18] *	1.84 [1.00, 3.37] *	1.97 [1.06, 3.65] *
Previous psychotherapy use
No	Reference	Reference	Reference	Reference
Yes	5.65 [2.72, 11.70] ***	4.41 [2.11, 9.20] ***	3.90 [1.85, 8.25] ***	2.86 [1.32, 6.20] **
Enabling factors
Reliable emotional support from partner
No partner	Reference		Reference	Reference
Partner, no reliable support	2.60 [1.22, 5.55] *		2.52 [1.11, 5.74] *	2.36 [1.05, 5.30] ˙
Partner, reliable support	0.78 [0.46, 1.35]		0.91 [0.51, 1.63]	1.11 [0.61, 2.01]
Reliable emotional support from children
No children	Reference		Reference	Reference
Children, no reliable support	0.74 [0.30, 1.83]		0.52 [0.20, 1.36]	0.59 [0.23, 1.53]
Children, reliable support	0.76 [0.39, 1.48]		0.85 [0.43, 1.70]	0.98 [0.49, 1.97]
Emotional support from other family members
No other family members	Reference		Reference	Reference
Family, no reliable support	1.02 [0.25, 4.25]		0.93 [0.22, 3.94]	1.03 [0.24, 4.38]
Family, reliable support	0.73 [0.18, 3.02]		0.64 [0.15, 2.65]	0.78 [0.18, 3.28]
Need factors
SF-36 mental component summary	0.95 [0.93, 0.97] ***			0.96 [0.94, 0.98] ***
SF-36 physical component summary	1.00 [0.97, 1.03]			1.00 [0.98, 1.03]
Charlson comorbidity index
0	Reference			Reference
≥ 1	0.69 [0.25, 1.87]			0.88 [0.31, 2.44]

Significance level: *** < 0.001, ** < 0.01, * < 0.05, ˙ < 0.1. ¹Age at diagnosis, gender, education, previous psychotherapy use; ²As the predisposing model, with emotional support from partner, children, and other family members added; ³As the predisposing and enabling model, with SF-36 mental and physical component summaries, and Charlson index scores added.

Table III. Hazard ratios with corresponding 95% confidence intervals (CIs) for psychotherapy use by 3646 patients within 18 months of first cancer diagnosis after 2002, with SF-36 mental component summary or subscales in fully adjusted model.†

SF-36 scales	Hazard ratio [95% CI]
Mental component summary	0.96 [0.94, 0.98] ***
Vitality	0.96 [0.94, 0.98] ***
Social functioning	0.97 [0.95, 1.0] *
Role emotional	0.96 [0.94, 0.99] **
Mental health	0.96 [0.94, 0.98] ***

Significance level: ***< 0.001, **< 0.01, *< 0.05. †Model containing predisposing, enabling and need factors, with SF-36 scales entered separately.

Andersen R. Revisiting the behavioral model and access to medical care: Does it matter? Health Soc Behav 1995;36:1–10.

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