Area-level variation in primary health care service characteristics and the modifying effect on individual-level socioeconomic variation in receipt of care: potential avenues for improving health equity

Abstract

The presence of a strong primary health care (PHC) system is crucial to improving not only the average levels of health of a population, but also health equity. While Australia has universal health care and a strong PHC system, service organisation and delivery characteristics vary according to the local context. However, the nature and extent of this variation and the way in which it modifies receipt of care in relation to a person’s socioeconomic position (SEP) is not well characterised. This thesis aimed to address these evidence gaps and, in so doing, identify avenues for policy and practice intervention for improving the equity of health care use. First, measures of service characteristics that reflect the core domains of strong PHC systems—accessibility (availability, affordability and accommodation), comprehensiveness and coordination—that can be viewed to operate at the small-area level were constructed. This was done using data available at the Statistical Area Level 3 for New South Wales, from a range of sources. There was marked geographical variation in these measures, and data and conceptual limitations warranted caution when applying some of them to PHC-related outcomes. Second, variation in receipt of PHC and the association with PHC service characteristics were quantified using 2006–2008 survey data from the 45 and Up Study linked to Medicare Benefits Schedule claims data and the constructed area-level PHC measures. Four outcomes were examined; frequency of GP use and three measures of quality—length of consultation, continuity of care and care planning. A series of two-level (individuals within areas) multilevel logistic regression models were run, separately by region (major cities, inner regional and outer regional/remote), and with cross-level interaction terms, to examine the effect of service characteristics on socioeconomic variation in receipt of care. Both GP use and quality of care varied between areas, within each region. People living in areas where care was more affordable (that is, more bulk-billing or less out-of-pocket expenses), or that had more after-hours or chronic disease care, had greater GP use and better quality of care. Generally, for a given level of need, persons of low SEP had more GP care (both GP use and quality of care) compared with their high-SEP counterparts. In major cities, increasing affordability or more after-hours services within an area was associated with a larger increase in GP care for persons of high SEP, compared with persons of low SEP. In contrast, in regional and remote areas, increasing affordability or more after-hours services within an area was associated with larger increases in use and a larger increase in long consultations for those who were low SEP compared with those who were high SEP; that is, these PHC characteristics were pro-low SEP. Using the same data and analytical approach, use of specialist care was also shown to vary between areas; however, in contrast to GP care, specialist use was pro-high SEP. The findings suggest that in major cities, PHC initiatives that promote affordability, accommodation and comprehensiveness of services within areas are working well from an equity perspective. On the other hand, in regional and remote areas there are clear opportunities for improving receipt of care for those who are disadvantaged through current policy initiatives. The inequitable use of speciality care sits in stark contrast to GP care, with significant potential for health gains by redressing this.