1. SPECIALIST REFERRAL RATES AND PATIENT NATIONALITY IN SPAIN Agency for Health Technology Assessment INSTITUTO DE SALUD CARLOS III Antonio Sarría Santamera Mª del Rocío Carmona Alférez Mª Auxiliadora Martín Martínez Pilar Gallego Berciano Enrique Regidor Poyatos

2. Sandín Vázquez M Conde Espejo P de Bustos Guadaño M Asunsolo del Barco A Riesgo Fuertes R Garrido Elustondo S Cabello Ballesteros ML Escortell Mayor ME Sanz Cuesta T Calvo Parra I Villaitodo Villén P Bartolomé Casado MS Jiménez Carramiñana J Casado López M Parralejo Buendía M Basanta López M Bonache Blay M Martínez-Toledano Olaya P Rico Blázquez M Primary Health Care Utilization Research Group

3. INTRODUCTION  The phenomenon of immigration is relatively new in Spain: the number of immigrants is low but increasing in the last few years.  12% of the population of Spain is of foreign nationality (INE, 2009).  44.8% of all registered immigrants in Spain reside in in three provinces (Madrid, Barcelona and Alicante).  The phenomenon of immigration is relatively new in Spain: the number of immigrants is low but increasing in the last few years.  12% of the population of Spain is of foreign nationality (INE, 2009).  44.8% of all registered immigrants in Spain reside in in three provinces (Madrid, Barcelona and Alicante).

4. INTRODUCTION Previous research indicates that the immigrant population is young and healthy, and there are no differences (age- adjusted). Although their health status could be similar to that of local populations, they could have different behaviors in accessing the health care system. Also, health care professionals could have different behavior when treating immigrants. Previous research indicates that the immigrant population is young and healthy, and there are no differences (age- adjusted). Although their health status could be similar to that of local populations, they could have different behaviors in accessing the health care system. Also, health care professionals could have different behavior when treating immigrants.

5. OBJECTIVE  To compare referrals to specialists from PC in the Region of Madrid between immigrant and native populations.

6. METHODOLOGY Design, location and sources of information  Design: transversal, observational and ecological.  Location : 6 health areas in the Community of Madrid.  Sources of information: - Electronic medical records of Primary Care (OMI-AP). - Institute of Statistics of the Community of Madrid. Design, location and sources of information  Design: transversal, observational and ecological.  Location : 6 health areas in the Community of Madrid.  Sources of information: - Electronic medical records of Primary Care (OMI-AP). - Institute of Statistics of the Community of Madrid. Health areas: 1, 3, 7, 8, 9 y 10

7. METHODOLOGY Flowchart of patient selection PATIENTS OVER 24 YEARS WITH AT LEAST ONE VISIT TO THE CENTRE OF HEALTH IN 2006 IN 6 HEALTH AREAS (1,325,327) PATIENTS INCLUDED IN STUDY (1,053,266) DUPLICATE PATIENTS (7,307) PATIENTS WITHOUT NATIONALITY (264,754)

8. METHODOLOGY PATIENT VARIABLES Socio-demographic 1. Age 2. Sex 3. Nationality 4. User Type 5. Social Problems Morbidity 1. Diseases (CIAP-1) 2. Temporary Disability 3. Patient Overview 4. Protocols 5. Drugs prescribed Use of Health Services 1. Total medical PC consultations (2006 and 2007). 2. Total nursing PC consultations (2006 and 2007). 3. Analytics 4. Radiology tests 5. Referrals to specialists PRIMARY CARE TEAM VARIABLES Organizational Characteristics and Health System Capacity 1. Location of the PCT 2. Type of primary health care team 3. Time schedule 2. Average PC doctor workload 3. Average PC nursing workload 4. Percentage of patients aged ≥ 65 years of primary care team Socioeconomic 1. Educational level of the Basic Health Zone (Population and Housing Census 2001 of the CM) 2. Per capita Gross Disposable Income of the Basic Health Zone (Statistical Institute of the CM)

9. METHODOLOGY  Nationality variable was used to reflect whether a patient was an immigrant or not.  8 categories of nationality: a)Native b)Western Countries c)Eastern Europe d)North Africa e)Sub-Saharan Africa f)Central America and Caribbean g)South America h)Middle East, South Asia and East  Nationality variable was used to reflect whether a patient was an immigrant or not.  8 categories of nationality: a)Native b)Western Countries c)Eastern Europe d)North Africa e)Sub-Saharan Africa f)Central America and Caribbean g)South America h)Middle East, South Asia and East

10. METHODOLOGY “SOCIO-ECONOMIC DATA” Patient Per capita Gross Disposable Income in 2000 of the Basic Health Zone “SOCIO-ECONOMIC DATA” Patient Per capita Gross Disposable Income in 2000 of the Basic Health Zone

11. METHODOLOGY MODEL 1: BINOMIAL REGRESSION  DEPENDENT VARIABLE: Referral (yes/no)  INDEPENDENTS VARIABLES:  Immigrant (yes/no)  Age  Sex  Total disease  Per capita income MODEL 1: BINOMIAL REGRESSION  DEPENDENT VARIABLE: Referral (yes/no)  INDEPENDENTS VARIABLES:  Immigrant (yes/no)  Age  Sex  Total disease  Per capita income Socio-demographic Morbidity Socio-economic

12. METHODOLOGY MODEL 2: BINOMIAL REGRESSION  DEPENDENT VARIABLE: Referral (yes/no)  INDEPENDENTS VARIABLES:  Nationality (8 categories)  Age  Sex  Total disease  Per capita income MODEL 2: BINOMIAL REGRESSION  DEPENDENT VARIABLE: Referral (yes/no)  INDEPENDENTS VARIABLES:  Nationality (8 categories)  Age  Sex  Total disease  Per capita income Socio-demographic Morbidity Socio-economic

13. RESULTS PATIENT CHARACTERISTICS (N=1,053,266) Both sexes (%) Male (%) Female (%) IMMIGRANT14.214.114.3 NATIONALITY OF IMMIGRANTS (n=149,564) Western Countries10.210.410.1 Eastern Europe18.317.618.9 North Africa10.813.88.4 Sub-Saharan Africa6.27.84.9 Central America and Caribbean6.95.68.0 South America42.939.545.7 Middle East, South Asia and East4.75.34.1

14. RESULTS PATIENT CHARACTERISTICSNATIVEIMMIGRANT (N=1,053,266)MeanS.D.MeanS.D. AGE50.3416.7939.9012.05 WOMEN (%)55.5 55.8 TOTAL NUMBER DISEASES5.694.013.843.10 PER CAPITA INCOME99772236102262609 REFERRALS0.430.770.420.77 CHARACTERISTICS OF PATIENTS REFERRED TO SPECIALISTNATIVEIMMIGRANT N=315,038MeanS.DMeanS.D. AGE51.9716.2440.6812.07 WOMEN (%)60.9066.57 TOTAL NUMBER DISEASES6.843.914.863.20 PER CAPITA INCOME96871841100072435 REFERRALS1.420.751.430.77

15. RESULTS REFERRALS TO SPECIALIST (N=1,053,266) Both sexes (%) Male (%) Female (%) NATIVE30.026.433.0 IMMIGRANT29.222.134.9 Western Countries27.423.430.6 Eastern Europe26.518.632.2 North Africa26.620.434.8 Sub-Saharan Africa26.620.134.9 Central America and Caribbean31.423.935.6 South America32.324.737.5 Middle East, South Asia and East22.216.927.7 TOTAL29.925.833.2

16. RESULTS

18. CONCLUSIONS  Immigrants are younger and healthier than the native population.  Overall, women have a higher probability of being referred to specialists.  After controlling for socio-demographic and economic characteristics, and morbidity, immigrants show a higher likelihood of referrals to specialist.

19. CONCLUSIONS  Compared to Spanish natives, specialist referrals are higher in women from those from Eastern Europe, Central and South America, and in men for those from South America.  Further studies will allow to gain a better understanding of the relationship between national origin and referrals.

20. THANK YOU