Association of individual-socioeconomic variation in quality-of-primary care with area-level service organisation: A multilevel analysis using linked data

Abstract

Rationale, aims and objectives: Ensuring equitable access to primary care (PC) contributes to reducing differences in health related to people's socioeconomic circumstances. However, there is limited data on system-level factors associated with equitable access to high-quality PC. We examine whether individual-level socioeconomic variation in general practitioner (GP) quality-of-care varies by area-level organisation of PC services.

Methods: Baseline data (2006-2009) from the Sax Institute's 45 and Up Study, involving 267,153 adults in New South Wales, Australia, were linked to Medicare Benefits Schedule claims and death data (to December 2012). Small area-level measures of PC service organisation were GPs per capita, bulk-billing (i.e., no copayment) rates, out-of-pocket costs (OPCs), rates of after-hours and chronic disease care planning/coordination services. Using multilevel logistic regression with cross-level interaction terms we quantified the relationship between area-level PC service characteristics and individual-level socioeconomic variation in need-adjusted quality-of-care (continuity-of-care, long-consultations, and care planning), separately by remoteness.

Results: In major cities, more bulk-billing and chronic disease services and fewer OPCs within areas were associated with an increased odds of continuity-of-care-more so among people of high- than low education (e.g., bulk-billing interaction with university vs. no school certificate 1.006 [1.000, 1.011]). While more bulk-billing, after-hours services and fewer OPCs were associated with long consultations and care planning across all education levels, in regional locations alone, more after-hours services were associated with larger increases in the odds of long consultations among people with low- than high education (0.970 [0.951, 0.989]). Area GP availability was not associated with outcomes.

Conclusions: In major cities, PC initiatives at the local level, such as bulk-billing and after-hours access, were not associated with a relative benefit for low- compared with high-education individuals. In regional locations, policies supporting after-hours access may improve access to long consultations, more so for people with low- compared with high-education.

Keywords: equity; multilevel analysis; primary care; socioeconomic inequalities; variation in care.