Does individual-socioeconomic variation in quality-of-primary care vary according to area-level service organisation? Multilevel analysis using linked data.

Abstract

Background There is limited data on system-level factors associated with equitable access to high-quality primary care. We examine whether individual-level socioeconomic variation in general practitioner (GP) quality-of-care varies by area-level organisation of primary healthcare (PHC) 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 and death data (to December 2012). Using multilevel logistic regression with cross-level interaction terms we quantified the relationship between small area-level PHC service characteristics and individual-level socioeconomic variation in need-adjusted quality-of-care (continuity-of-care, long-consultations, and care planning), separately by remoteness. Key findings In major cities, more bulk-billing(i.e. no co-payment) and chronic disease services and fewer out-of-pocket costs 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 versus no school certificate 1.006[1.000,1.011]). While more bulk-billing, after-hours services and fewer OPC 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. Implications In major cities, PHC initiatives at the local level, such as bulk-billing and after-hours access, were not associated with a relative benefit for low- compared to high-education individuals. In regional locations, policies supporting after-hour access may improve access to long consultations, more so for people with low- compared to high-education.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This research was supported through a grant from the Australian Government through the National Health and Medical Research Council Postgraduate Scholarship (GNT1038903).

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethics approval for this project was obtained from the NSW Population and Health Services Research Ethics Committee (HREC/13/CIPHS/8) and the Australian National University Human Research Ethics Committee (2011/703).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Yes

Data Availability

The data that support the findings of this study are available from the Sax Institute, NSW but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data from the Sax Institute's 45 and Up Study are available for approved projects to approved researchers (www.saxinstitute.org.au).

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