Investigating the relationship between unmet need and utilisation of health care in European countries.

Access to health care is a multidimensional concept, influenced by individual and health system factors and the relationship between different access dimensions is not well understood. We used individual-level data from the 2019 wave of the European Health Interview Survey, covering 27 European Union member states, Iceland, and Norway (n = 269,799 individuals) and country-level data from the Eurostat, OECD and World Bank databases to explore this important research gap. We investigated six outcome measures: unmet need due to long wait, distance, affordability of medical care, and affordability of prescribed medicines, and the utilisation of general practitioner, or specialist care. We investigated the relationship between these outcomes and individual characteristics using a multilevel multivariate logit random effects model, which allowed us to model outcomes simultaneously. After controlling for individual socio-economic position, health status and health behaviour, we assessed the correlation between outcomes at individual and country levels to gain insight into the relationship between different dimensions of access. We investigated the association between each outcome measure and health system characteristics including health expenditure, physician density and primary care gatekeeping as well as macroeconomic characteristics (income and income inequality) using multilevel logit random effects models. We found that people with lower self-reported health status, multimorbidity and limitations due to health problems were more likely to report unmet need and utilisation. Higher household income was negatively associated with unmet need and positively associated with utilisation. After controlling for individual characteristics, correlations between unmet need and utilisation were very low (under 10%) at individual level. At country level, there was a negative correlation between unmet need due to the affordability of prescribed medicines and GP (-49%), and specialist (-42%) care. Individuals in countries that incentivised or required a referral from primary to specialist care were less likely to report use of specialist care. Our findings emphasise that unmet need and utilisation measure different dimensions of access, thus underscoring the importance of employing complementary measures of access to health care.