Open Access Research article

Assessing socioeconomic health care utilization inequity in Israel: impact of alternative approaches to morbidity adjustment

Efrat Shadmi12, Ran D Balicer23*, Karen Kinder4, Chad Abrams4 and Jonathan P Weiner4

Author Affiliations

1 Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel 31905, Israel

2 2 Clalit Research Institute and Health Policy Planning Department, Chief Physician's Office, Clalit Health Services, 101 Arlozorov St, Tel Aviv 62098, Israel

3 Epidemiology Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva 84105, Israel

4 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA

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BMC Public Health 2011, 11:609  doi:10.1186/1471-2458-11-609

Published: 1 August 2011



The ability to accurately detect differential resource use between persons of different socioeconomic status relies on the accuracy of health-needs adjustment measures. This study tests different approaches to morbidity adjustment in explanation of health care utilization inequity.


A representative sample was selected of 10 percent (~270,000) adult enrolees of Clalit Health Services, Israel's largest health care organization. The Johns-Hopkins University Adjusted Clinical Groups® were used to assess each person's overall morbidity burden based on one year's (2009) diagnostic information. The odds of above average health care resource use (primary care visits, specialty visits, diagnostic tests, or hospitalizations) were tested using multivariate logistic regression models, separately adjusting for levels of health-need using data on age and gender, comorbidity (using the Charlson Comorbidity Index), or morbidity burden (using the Adjusted Clinical Groups). Model fit was assessed using tests of the Area Under the Receiver Operating Characteristics Curve and the Akaike Information Criteria.


Low socioeconomic status was associated with higher morbidity burden (1.5-fold difference). Adjusting for health needs using age and gender or the Charlson index, persons of low socioeconomic status had greater odds of above average resource use for all types of services examined (primary care and specialist visits, diagnostic tests, or hospitalizations). In contrast, after adjustment for overall morbidity burden (using Adjusted Clinical Groups), low socioeconomic status was no longer associated with greater odds of specialty care or diagnostic tests (OR: 0.95, CI: 0.94-0.99; and OR: 0.91, CI: 0.86-0.96, for specialty visits and diagnostic respectively). Tests of model fit showed that adjustment using the comprehensive morbidity burden measure provided a better fit than age and gender or the Charlson Index.


Identification of socioeconomic differences in health care utilization is an important step in disparity reduction efforts. Adjustment for health-needs using a comprehensive morbidity burden diagnoses-based measure, this study showed relative underutilization in use of specialist and diagnostic services, and thus allowed for identification of inequity in health resources use, which could not be detected with less comprehensive forms of health-needs adjustments.