Economic, cultural, and social inequalities in potentially inappropriate medication: A nationwide survey- and register-based study in Denmark

Amanda Paust; Claus Vestergaard; Susan M Smith; Karina Friis; Stine Schramm; Flemming Bro; Anna Mygind; Nynne Bech Utoft; James Larkin; Anders Prior

doi:10.1371/journal.pmed.1004473

Economic, cultural, and social inequalities in potentially inappropriate medication: A nationwide survey- and register-based study in Denmark

Amanda Paust^*, Claus Vestergaard, Susan M Smith, Karina Friis, Stine Schramm, Flemming Bro, Anna Mygind, Nynne Bech Utoft, James Larkin, Anders Prior

^*Corresponding author for this work

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

Abstract

BACKGROUND: Potentially inappropriate medication (PIM) is associated with negative health outcomes and can serve as an indicator of treatment quality. Previous studies have identified social inequality in treatment but often relied on narrow understandings of social position or failed to account for mediation by differential disease risk among social groups. Understanding how social position influences PIM exposure is crucial for improving the targeting of treatment quality and addressing health disparities. This study investigates the association between social position and PIM, considering the mediation effect of long-term conditions.

METHODS AND FINDINGS: This cross-sectional study utilized data from the 2017 Danish National Health Survey, including 177,495 individuals aged 18 or older. Data were linked to national registers on individual-level. PIM was defined from the STOPP/START criteria and social position was assessed through indicators of economic, cultural, and social capital (from Bourdieu's Capital Theory). We analyzed odds ratios (ORs) and prevalence proportion differences (PPDs) for PIM using logistic regression, negative binomial regression, and generalized structural equation modeling. The models were adjusted for age and sex and analyzed separately for indicators of under- (START) and overtreatment (STOPP). The mediation analysis was conducted to separate direct and indirect effects via long-term conditions. Overall, 14.7% of participants were exposed to one or more PIMs, with START PIMs being more prevalent (12.5%) than STOPP PIMs (3.1%). All variables for social position except health education were associated with PIM in a dose-response pattern. Individuals with lower wealth (OR: 1.85 [95% CI 1.77, 1.94]), lower income (OR: 1.78 [95% CI 1.69, 1.87]), and lower education level (OR: 1.66 [95% CI 1.56, 1.76]) exhibited the strongest associations with PIM. Similar associations were observed for immigrants, people with low social support, and people with limited social networks. The association with PIM remained significant for most variables after accounting for mediation by long-term conditions. The disparities were predominantly related to overtreatment and did not relate to the number of PIMs. The study's main limitation is the risk of reverse causation due to the complex nature of social position and medical treatment.

CONCLUSIONS: The findings highlight significant social inequalities in PIM exposure, driven by both economic, cultural, and social capital despite a universal healthcare system. Understanding the social determinants of PIM can inform policies to reduce inappropriate medication use and improve healthcare quality and equity.

Original language	English
Article number	e1004473
Journal	PLOS Medicine
Volume	21
Issue	11
Number of pages	18
ISSN	1549-1277
DOIs	https://doi.org/10.1371/journal.pmed.1004473
Publication status	Published - Nov 2024

Keywords

Humans
Denmark
Male
Female
Middle Aged
Cross-Sectional Studies
Adult
Aged
Socioeconomic Factors
Adolescent
Young Adult
Registries
Potentially Inappropriate Medication List
Inappropriate Prescribing/statistics & numerical data
Healthcare Disparities

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10.1371/journal.pmed.1004473Licence: CC BY

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@article{31e3c907441f4122917f00cd9f71bd72,

title = "Economic, cultural, and social inequalities in potentially inappropriate medication: A nationwide survey- and register-based study in Denmark",

abstract = "BACKGROUND: Potentially inappropriate medication (PIM) is associated with negative health outcomes and can serve as an indicator of treatment quality. Previous studies have identified social inequality in treatment but often relied on narrow understandings of social position or failed to account for mediation by differential disease risk among social groups. Understanding how social position influences PIM exposure is crucial for improving the targeting of treatment quality and addressing health disparities. This study investigates the association between social position and PIM, considering the mediation effect of long-term conditions.METHODS AND FINDINGS: This cross-sectional study utilized data from the 2017 Danish National Health Survey, including 177,495 individuals aged 18 or older. Data were linked to national registers on individual-level. PIM was defined from the STOPP/START criteria and social position was assessed through indicators of economic, cultural, and social capital (from Bourdieu's Capital Theory). We analyzed odds ratios (ORs) and prevalence proportion differences (PPDs) for PIM using logistic regression, negative binomial regression, and generalized structural equation modeling. The models were adjusted for age and sex and analyzed separately for indicators of under- (START) and overtreatment (STOPP). The mediation analysis was conducted to separate direct and indirect effects via long-term conditions. Overall, 14.7% of participants were exposed to one or more PIMs, with START PIMs being more prevalent (12.5%) than STOPP PIMs (3.1%). All variables for social position except health education were associated with PIM in a dose-response pattern. Individuals with lower wealth (OR: 1.85 [95% CI 1.77, 1.94]), lower income (OR: 1.78 [95% CI 1.69, 1.87]), and lower education level (OR: 1.66 [95% CI 1.56, 1.76]) exhibited the strongest associations with PIM. Similar associations were observed for immigrants, people with low social support, and people with limited social networks. The association with PIM remained significant for most variables after accounting for mediation by long-term conditions. The disparities were predominantly related to overtreatment and did not relate to the number of PIMs. The study's main limitation is the risk of reverse causation due to the complex nature of social position and medical treatment.CONCLUSIONS: The findings highlight significant social inequalities in PIM exposure, driven by both economic, cultural, and social capital despite a universal healthcare system. Understanding the social determinants of PIM can inform policies to reduce inappropriate medication use and improve healthcare quality and equity.",

keywords = "Humans, Denmark, Male, Female, Middle Aged, Cross-Sectional Studies, Adult, Aged, Socioeconomic Factors, Adolescent, Young Adult, Registries, Potentially Inappropriate Medication List, Inappropriate Prescribing/statistics & numerical data, Healthcare Disparities",

author = "Amanda Paust and Claus Vestergaard and Smith, {Susan M} and Karina Friis and Stine Schramm and Flemming Bro and Anna Mygind and {Bech Utoft}, Nynne and James Larkin and Anders Prior",

year = "2024",

month = nov,

doi = "10.1371/journal.pmed.1004473",

language = "English",

volume = "21",

journal = "PLOS Medicine",

issn = "1549-1277",

publisher = "Public Library of Science",

number = "11",

}

Economic, cultural, and social inequalities in potentially inappropriate medication: A nationwide survey- and register-based study in Denmark. / Paust, Amanda; Vestergaard, Claus; Smith, Susan M et al.
In: PLOS Medicine, Vol. 21, No. 11, e1004473, 11.2024.

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

TY - JOUR

T1 - Economic, cultural, and social inequalities in potentially inappropriate medication

T2 - A nationwide survey- and register-based study in Denmark

AU - Paust, Amanda

AU - Vestergaard, Claus

AU - Smith, Susan M

AU - Friis, Karina

AU - Schramm, Stine

AU - Bro, Flemming

AU - Mygind, Anna

AU - Bech Utoft, Nynne

AU - Larkin, James

AU - Prior, Anders

PY - 2024/11

Y1 - 2024/11

N2 - BACKGROUND: Potentially inappropriate medication (PIM) is associated with negative health outcomes and can serve as an indicator of treatment quality. Previous studies have identified social inequality in treatment but often relied on narrow understandings of social position or failed to account for mediation by differential disease risk among social groups. Understanding how social position influences PIM exposure is crucial for improving the targeting of treatment quality and addressing health disparities. This study investigates the association between social position and PIM, considering the mediation effect of long-term conditions.METHODS AND FINDINGS: This cross-sectional study utilized data from the 2017 Danish National Health Survey, including 177,495 individuals aged 18 or older. Data were linked to national registers on individual-level. PIM was defined from the STOPP/START criteria and social position was assessed through indicators of economic, cultural, and social capital (from Bourdieu's Capital Theory). We analyzed odds ratios (ORs) and prevalence proportion differences (PPDs) for PIM using logistic regression, negative binomial regression, and generalized structural equation modeling. The models were adjusted for age and sex and analyzed separately for indicators of under- (START) and overtreatment (STOPP). The mediation analysis was conducted to separate direct and indirect effects via long-term conditions. Overall, 14.7% of participants were exposed to one or more PIMs, with START PIMs being more prevalent (12.5%) than STOPP PIMs (3.1%). All variables for social position except health education were associated with PIM in a dose-response pattern. Individuals with lower wealth (OR: 1.85 [95% CI 1.77, 1.94]), lower income (OR: 1.78 [95% CI 1.69, 1.87]), and lower education level (OR: 1.66 [95% CI 1.56, 1.76]) exhibited the strongest associations with PIM. Similar associations were observed for immigrants, people with low social support, and people with limited social networks. The association with PIM remained significant for most variables after accounting for mediation by long-term conditions. The disparities were predominantly related to overtreatment and did not relate to the number of PIMs. The study's main limitation is the risk of reverse causation due to the complex nature of social position and medical treatment.CONCLUSIONS: The findings highlight significant social inequalities in PIM exposure, driven by both economic, cultural, and social capital despite a universal healthcare system. Understanding the social determinants of PIM can inform policies to reduce inappropriate medication use and improve healthcare quality and equity.

AB - BACKGROUND: Potentially inappropriate medication (PIM) is associated with negative health outcomes and can serve as an indicator of treatment quality. Previous studies have identified social inequality in treatment but often relied on narrow understandings of social position or failed to account for mediation by differential disease risk among social groups. Understanding how social position influences PIM exposure is crucial for improving the targeting of treatment quality and addressing health disparities. This study investigates the association between social position and PIM, considering the mediation effect of long-term conditions.METHODS AND FINDINGS: This cross-sectional study utilized data from the 2017 Danish National Health Survey, including 177,495 individuals aged 18 or older. Data were linked to national registers on individual-level. PIM was defined from the STOPP/START criteria and social position was assessed through indicators of economic, cultural, and social capital (from Bourdieu's Capital Theory). We analyzed odds ratios (ORs) and prevalence proportion differences (PPDs) for PIM using logistic regression, negative binomial regression, and generalized structural equation modeling. The models were adjusted for age and sex and analyzed separately for indicators of under- (START) and overtreatment (STOPP). The mediation analysis was conducted to separate direct and indirect effects via long-term conditions. Overall, 14.7% of participants were exposed to one or more PIMs, with START PIMs being more prevalent (12.5%) than STOPP PIMs (3.1%). All variables for social position except health education were associated with PIM in a dose-response pattern. Individuals with lower wealth (OR: 1.85 [95% CI 1.77, 1.94]), lower income (OR: 1.78 [95% CI 1.69, 1.87]), and lower education level (OR: 1.66 [95% CI 1.56, 1.76]) exhibited the strongest associations with PIM. Similar associations were observed for immigrants, people with low social support, and people with limited social networks. The association with PIM remained significant for most variables after accounting for mediation by long-term conditions. The disparities were predominantly related to overtreatment and did not relate to the number of PIMs. The study's main limitation is the risk of reverse causation due to the complex nature of social position and medical treatment.CONCLUSIONS: The findings highlight significant social inequalities in PIM exposure, driven by both economic, cultural, and social capital despite a universal healthcare system. Understanding the social determinants of PIM can inform policies to reduce inappropriate medication use and improve healthcare quality and equity.

KW - Humans

KW - Denmark

KW - Male

KW - Female

KW - Middle Aged

KW - Cross-Sectional Studies

KW - Adult

KW - Aged

KW - Socioeconomic Factors

KW - Adolescent

KW - Young Adult

KW - Registries

KW - Potentially Inappropriate Medication List

KW - Inappropriate Prescribing/statistics & numerical data

KW - Healthcare Disparities

UR - http://www.scopus.com/inward/record.url?scp=85209907788&partnerID=8YFLogxK

U2 - 10.1371/journal.pmed.1004473

DO - 10.1371/journal.pmed.1004473

M3 - Journal article

C2 - 39565747

SN - 1549-1277

VL - 21

JO - PLOS Medicine

JF - PLOS Medicine

IS - 11

M1 - e1004473

ER -

Economic, cultural, and social inequalities in potentially inappropriate medication: A nationwide survey- and register-based study in Denmark

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Keywords

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