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

BackgroundThere 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. MethodsBaseline data (2006-2009) from the Sax Institutes 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 findingsIn 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. ImplicationsIn 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. Key messagesO_ST_ABSWhat we knowC_ST_ABSO_LIEquitable access to high-quality primary healthcare is expected to reduce socioeconomic inequalities in health. C_LIO_LIQuality-of-care varies according to both individual socioeconomic position and local primary healthcare service organisation and delivery. C_LIO_LIHowever, there is limited data on system-level factors associated with equitable access to high-quality care. C_LI What this study addsO_LIIn major cities, area-level primary healthcare service characteristics such as bulk-billing (i.e. no co-payment), out-of-pocket costs, chronic disease and after-hours services were not associated with a relative benefit for low-education individuals compared with high-education in quality-of-care. C_LIO_LIIn regional areas, more after-hours services were associated with a higher likelihood of long consultations - more so for people of low-education than high-education. C_LI How this study might affect research, practice or policyO_LIThe identified area-level service characteristics associated with socioeconomic variation in care indicate avenues for providers and policy makers for improving healthcare equity. C_LIO_LIImproved data measuring area-level primary healthcare service organisation is needed to better measure the impact of policy initiatives. C_LI