Racial and socioeconomic disparities in multimorbidity and associated healthcare utilisation and outcomes in Brazil: a cross-sectional analysis of three million individuals

Abstract

Background: Evidence is limited on racial/ethnic group disparities in multimorbidity and associated health outcomes in low- and middle-income countries hampering effective policies and clinical interventions to address health inequalities.

Methods: This study assessed race/ethnic and socioeconomic disparities in the prevalence of multimorbidity and associated healthcare utilisation, costs and death in Rio de Janeiro, Brazil. A cross-sectional analysis was carried out of 3,027,335 individuals registered with primary healthcare (PHC) services. Records included linked data to hospitalisation, mortality, and welfare-claimant (Bolsa Família) records between 1 Jan 2012 and 31 Dec 2016. Logistic and Poisson regression models were carried out to assess the likelihood of multimorbidity (two or more diagnoses out of 53 chronic conditions), PHC use, hospital admissions and mortality from any cause. Interactions were used to assess disparities.

Results: In total 13,509,633 healthcare visits were analysed identifying 389,829 multimorbid individuals (13%). In adjusted regression models, multimorbidity was associated with lower education (Adjusted Odds Ratio (AOR): 1.26; 95%CI: 1.23,1.29; compared to higher education), Bolsa Família receipt (AOR: 1.14; 95%CI: 1.13,1.15; compared to non-recipients); and black race/ethnicity (AOR: 1.05; 95%CI: 1.03,1.06; compared to white). Multimorbidity was associated with more hospitalisations (Adjusted Rate Ratio (ARR): 2.75; 95%CI: 2.69,2.81), more PHC visits (ARR: 3.46; 95%CI: 3.44,3.47), and higher likelihood of death (AOR: 1.33; 95%CI: 1.29,1.36). These associations were greater for multimorbid individuals with lower educational attainment (five year probability of death 1.67% (95%CI: 1.61,1.74%) compared to 1.13% (95%CI: 1.02,1.23%) for higher education), individuals of black race/ethnicity (1.48% (95%CI: 1.41,1.55%) compared to 1.35% (95%CI: 1.31,1.40%) for white) and individuals in receipt of welfare (1.89% (95%CI: 1.77,2.00%) compared to 1.35% (95%CI: 1.31,1.38%) for non-recipients).

Conclusions: The prevalence of multimorbidity and associated hospital admissions and mortality are greater in individuals with black race/ethnicity and other deprived socioeconomic groups in Rio de Janeiro. Interventions to better prevent and manage multimorbidity and underlying disparities in low- and middle-income country settings are needed.

Keywords: Brazil; Chronic conditions; Hospitalisations; Middle-income country; Mortality; Multimorbidity; Utilisation.

Fig. 1

Prevalence of number of chronic conditions by age

Fig. 2

Prevalence of multimorbidity across ethnicity/racial and educational groups by age. Indigenous racial group omitted due to low numbers. Lowest education includes individuals with no schooling, literacy classes, preschool or elementary school (Grades 1–4) attainment. Midlevel education includes individuals with educational attainment of elementary School (Grades 5+) or high-school

Fig. 3

Five-year predicted numbers of PHC consultations and hospitalisations and probability of death. Predicted probabilities and rates obtained from adjusted regression models including age, sex, race, insurance status, education, Bolsa Família recipient status, multimorbidity diagnosis, and three interactions between multimorbidity status and education, race, and Bolsa Família recipient status. Predicted probabilities and rates interpreted relative to five-year observation period. MM – Multimorbidity

Fig. 4

Predicted monthly household expenditures on medicines. Predicted monthly expenditures obtained from adjusted linear regression model including age, sex, race, insurance status, education, Bolsa Família recipient status, multimorbidity diagnosis, and three interactions between multimorbidity status and education, race, and Bolsa Família recipient status