Abstract
Background: Immigration is a relevant public health issue and there is a great deal of controversy surrounding its impact on health services utilization.
Objective: To determine differences between immigrants and non-immigrants in the utilization of primary health care services in Catalonia, Spain.
Methods: Population based, cross-sectional, multicentre study. We used the information from 16 primary health care centres in an area near Barcelona, Spain. We conducted a multilevel analysis for the year 2008 to compare primary health care services utilization between all immigrants aged 15 or more and a sample of non-immigrants, paired by age and sex.
Results: Overall, immigrants living in Spain used health services more than non-immigrants (Incidence Risk Ratio (IRR) 1.16 (95% Confidence Interval (CI): 1.15 – 1.16) and (IRR 1, 26, 95% CI: 1.25–1.28) for consultations with GPs and referrals to specialized care, respectively. People coming from the Maghreb and the rest of Africa requested the most consultations involving a GP and nurses (IRR 1.34, 95% CI: 1.33–1.36 and IRR 1.06, 95% CI: 1.03–1.44, respectively). They were more frequently referred to specialized care (IRR 1.44, 95% CI: 1.41–1.46) when compared to Spaniards. Immigrants from Asia had the lowest numbers of consultations with a GP and referrals (IRR 0.76, 95% CI: 0.66–0.88 and IRR 0.76, 95% CI: 0.61–0.95, respectively.
Conclusion: On average, immigrants living in Catalonia used the health services more than non-immigrants. Immigrants from the Maghreb and other African countries showed the highest and those from Asia the lowest, number of consultations and referrals to specialized care.
KEY MESSAGE:
Primary health care utilization by immigrants as compared to the native population: A multilevel analysis of a large clinical database in Catalonia.
INTRODUCTION
Although immigration has always existed, the arrival of numerous, economy-based immigrants to Europe in recent years has become a relevant social issue, which has obliged the host countries to adapt their social, cultural, and health systems (Citation1). In Spain, immigration has increased from 2.5% to 12 % of the total population in the last decade (Citation2). Since the Spanish National Health System provides a universal and free coverage, population growth due to immigration has become a major issue with respect to both financial concerns and the workload of health professionals (Citation3,Citation4). The services overload is particularly marked in the areas of Madrid and Catalonia where most of the immigrant population is concentrated (Citation5).
Results from studies analysing differences between immigrant and non-immigrant populations in the utilization of health care vary according to the health system of the host country and the country of origin of the immigrants (Citation6,Citation7). Whereas the quantity of research on immigrant health care utilization in Spain is increasing, most available information still comes from other countries with a longer tradition in hosting immigrants (Citation8). Health care structure varies across Europe and accessibility and primary care are not the same. In addition, the wide range of methodologies used in the design of these studies makes the comparison of results difficult (Citation9).
In most cases, information used in the analyses was based on self-referred or aggregated data (Citation10,Citation11). Studies containing individual and clinical information are scarce. We designed a study to analyse the use of primary health care services by immigrants in a universal coverage health system, using a large clinical database, which contained all information related to health services utilization.
METHODS
Design
A cross-sectional, multicentre study based on clinical registries.
Patient data: The clinical database ‘e-CAP’
In all primary health care centres of the Catalan Institute of Health, electronic medical records (EMR) were fully implemented during the year 2005. Participants were living in the Valles Oriental, a region of Catalonia (Spain). Primary healthcare in this area is provided by 16 practices, covering a total of 386 676 people. All people attending primary health care centres in the years 2005–2008 were included in an electronic health care database (e-CAP). Information available consists of socio-demographic data, clinical diagnoses coded according to the International Classification of Diseases version 10 (ICD-10) (Citation12), laboratory tests, health services utilization, and prescriptions. Patients not using the primary health care services in the study area between 2005 and 2008 were excluded. Data of patients born before 1 January 1993 (aged 15 years or more) and assigned to a general practitioner's list by 31 December 2008 were included in the analyses.
Selection of both study populations
To select the immigrant and Spanish study populations, the administrative information from medical records, which usually included the country of origin, was consulted. If the information about the country was not registered, but the participants did have a Spanish identity card they were considered to be Spanish. The remaining cases were included in the category of ‘non-coded’ country and considered separately in the analysis.
Patients who came from a country other than Spain or did not have a Spanish identity card were first identified. All immigrants who met the eligibility criteria were included. The same number of Spaniards was randomly recruited from the general database and paired according to sex and an age (within a range of three years).
Variables
Available socio-demographic information was registered; age, sex, and country of origin.
Immigrants were grouped into geographical areas in accordance with other publications as follows: European Union before 2004 except Spain (Belgium, the Netherlands, Luxembourg, France, Italy, Germany, Ireland, UK, Denmark, Austria, Sweden, Finland, Greece and Portugal); countries incorporated into the European Union after 2004 (Malta, Cyprus, Estonia, Latvia, Lithuania, Poland, Czech Republic, Slovakia, Slovenia and Hungary); the Maghreb (Morocco, Tunisia, Algeria); the rest of Africa; Latin America; Asia and others (the USA and countries with a very scarce representation) (Citation13).
The following variables related to the utilization of the health services were used: primary care requested consultations with general practitioners (GPs) and nurses, respectively; and referrals to specialized care.
To determine health status, analysis of the total number of health problems registered in the clinical records according to the ICD-10 was performed. This variable was used to fit the multivariate analysis, as it could be a confounding factor for health services utilization.
Statistical analysis
In the descriptive analysis, the proportion of patients in each group for categorical variables and the median values for continuous variables was calculated.
A multilevel Poisson regression was performed to investigate the association between immigrants and health services indicators (incorporating each primary health care centre in the mathematical model). The dataset was presented at two hierarchical levels: patient (lower level) and GP (higher level) to reduce variability due to the health professionals. A Poisson regression model was estimated for each outcome with random intercept and fixed regression coefficients for independent variables at the two levels (Citation14). Incidence Rate Ratio (IRR) and 95% Confidence Intervals (CI) were calculated for fixed effects, adjusted by age, sex, and health status. The level of significance was established at P < 0.05. All the calculations were made in Stata Release 11 and SPSS 16.0.
RESULTS
Descriptive analysis
Data analysis was preformed of 31 625 immigrants and 31 632 Spaniards who had used primary health care service in the study area during 2008. Most immigrants came from Latin America (36.0% of all immigrants), the Maghreb (18.1 %), and the rest of the Africa (17.2%). Immigrants from Latin American countries and those who have recently joined the European Union were more mostly women, whereas those from Asiatic and African countries were predominantly men ().
Table I. Sex and country of origin of population studied.
Health services utilization
The median of requested consultations was higher in immigrants than in non-immigrants: median 4, interquartile range 1–8 versus median 3, interquartile range 1–8, respectively (P < 0.001). Most consultations were requested by patients coming from the Maghreb, the rest of Africa, and Latin American countries (). In contrast, individuals from the recent European Union countries asked less for consultations. The number of consultations involving nurses was very low in all groups. People from the Maghreb, Africa, and Latin-America were more frequently referred to specialized care than others.
Table II. Descriptive analysis reflecting health service utilization depending on the country of origin (aggregated in regions).
In 37 694 visits (12.3%), patients did not attend the consultations they had previously requested. This issue of non-attendance was especially marked in the case of the immigrants coming from the Maghreb (17.9%), followed by Latin America (15.6%) and the rest of Africa (14.7%), respectively. With respect to Spaniards, the percentage of non-attendance was 9.4%.
Health status
The percentage of immigrants who had registered a number of diagnoses above the median was 42.8%, whereas in the case of Spaniards it was 50.87% (P < 0.001, median = 1).
When comparing the health status of the Spanish population and the immigrants by using ICD-10 chapters, it can be noted that—except for a few ICD-chapters, Spaniards had a higher registered morbidity () than other participants.
Table III. Comparison of health status between Spaniards and immigrants. by using ICD-10 chapters.
Health services utilization
reflects the results from the multilevel analysis adjusted by age, sex, and health status. Overall, immigrants living in Spain used health services (consultations with GPs, referrals to specialized care) more than Spaniards. People coming from the Maghreb and the rest of Africa, requested more consultations involving GPs and nurses and were more frequently referred to specialists than the Spanish ones. Asian immigrants, however, had the lowest figures in all domains analysed, even in comparison with Spaniards.
Table IV. Multilevel analysis of health service utilization depending on the country of origin aggregated in regions. Reference categories are male and Spain. The model is adjusted by age, sex, and health status.
DISCUSSION
The use of health care services by immigrants varied depending on their country of origin. People coming from Latin-America, the Maghreb, and the rest of Africa requested more consultations with GPs, whereas those coming from countries recently added to the European Union (Eastern Europe) or Asia asked for fewer consultations than the Spanish population. With the exception of the Asian population, who had the lowest health care utilization figures, immigrants—those from the Maghreb and other African countries in particular—were also more often referred to specialized care than the Spanish.
Strengths and limitations
A multilevel analysis was carried out to eliminate the effect of variability due to the large number of health care professionals attending the population included in the study.
The results are only representative for patients who attended the primary care services, since those who did not request medical consultations were not included in the analysis. This is an important distinction, since the possibility that immigrants in fact consume fewer health care resources than the majority population, cannot be excluded.
Interpretation
This is the first large-scale study concerning the Spanish Health System and immigrants using population based data and clinical information. Results are consistent with those from a recent national report that showed higher health services utilization by immigrants (Citation9) and with previous studies on primary health care in Spain (Citation5).
It is difficult, however, to compare the results with those from other countries because of the differences in the accessibility and structure of each health care system. In some reports, immigrants from countries with a weaker primary care showed a lower use of these services (Citation15), whereas other studies underlined a wide variability depending on sex or age of immigrants (Citation16,Citation17). Moreover, contradictory results have been reported on the utilization of health services with respect to both the country of origin and culture-related beliefs (Citation15,Citation18).
Since morbidity was usually higher in the Spanish population, differences in health status found between Spaniards and immigrants seem not influence the higher utilization of health services by the last ones. It could be due to the fact that people born and living in Spain have had more opportunities to attend their GPs.
Primary health care accessibility is universal and free in Spain. Legislation grants the right of every individual on Spanish territory, to have access to emergency services and the necessary subsequent medical care. Immigrants coming from the European Union, or having permission to reside in Spain, have the same rights as the Spanish population. In the Spanish health care system, specialized care cannot be obtained without authorization from a GP, a situation that could condition accessibility. Nevertheless, a higher number of referrals of immigrants to specialized care is found. Whilst these findings are in contrast with results obtained by some other authors, they are consistent with a number of European studies, especially when Latin-Americans are involved (Citation20–22).
An interesting finding of this study was the higher percentage of previously scheduled consultations that were not finally attended by immigrants. Patient non-attendance is an area of concern for all providers of health care, as it incurs costs and results in a loss of clinical time.
As other authors have previously described, Asian immigrants in this study used health services the least frequent (Citation23,Citation24). As these participants were not interviewed we do not know the cause of this lower utilization. We did observe, however, that immigrants from the Maghreb and African countries used primary care services more often than the native population. A similar finding was reported in a study from the Netherlands (Citation25).
Implications
Finding variability in indicators of health care utilization does not provide the reasons for these differences. Further quantitative and qualitative research is needed among attendees as well as non-attendees. Additional information on encounter and morbidity patterns is necessary. By interviewing samples of immigrants and natives, we could explore health beliefs and attitudes, as well as opinions, concerning the ideal health care system.
The results of this study can, however, help health administrators to plan immigrant health care.
Conclusion
On average, immigrants living in Catalonia used health services more than non-immigrants. Immigrants from the Maghreb and other African countries showed the highest and those from Asia the lowest figures.
ACKNOWLEDGEMENTS
The authors are grateful to Maria José Torras for her contribution in facilitating data access and Stephanie Lonsdale for reviewing the English version of the manuscript.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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