National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia.
College of Medicine and Dentistry, James Cook University, Townsville, Australia.
J Eval Clin Pract. 2023 Sep;29(6):984-997. doi: 10.1111/jep.13834. Epub 2023 Mar 9.
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.
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.
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.
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.
背景、目的和目标：确保初级保健（PC）的公平可及性有助于减少与人们社会经济状况相关的健康差异。然而，关于与高质量 PC 的公平可及性相关的系统层面因素的数据有限。我们研究了个体层面的全科医生（GP）护理质量的社会经济差异是否因 PC 服务的区域层面组织而异。
我们对澳大利亚新南威尔士州 267153 名成年人进行了萨克研究所 45 岁及以上研究的基线数据分析（2006-2009 年），并将其与医疗保险福利计划索赔和死亡数据（截至 2012 年 12 月）进行了关联。PC 服务组织的小区域水平测量指标包括人均 GP、按人头计费（即不收取自付费用）的比例、自付费用（OPC）、下班后和慢性病护理计划/协调服务的比例。我们使用具有跨水平交互项的多层次逻辑回归来量化区域层面 PC 服务特征与个体层面社会经济需求调整后的护理质量（连续性护理、长咨询和护理计划）之间的关系，分别按偏远程度进行。
在主要城市，更多的按人头计费和慢性病服务以及较少的 OPC 与较高（而非较低）教育程度人群的连续性护理机会增加相关（例如，与大学相比，与没有学校证书的人群的按人头计费交互作用为 1.006 [1.000, 1.011]）。尽管更多的按人头计费、下班后服务和较少的 OPC 与所有教育水平的长咨询和护理计划相关，但仅在区域位置，更多的下班后服务与较低教育程度人群的长咨询机会增加相关（0.970 [0.951, 0.989]）。区域 GP 可用性与结果无关。
在主要城市，地方一级的 PC 举措，如按人头计费和下班后就诊，与低教育程度个体相比，对高教育程度个体没有相对益处。在区域位置，支持下班后就诊的政策可能会改善长咨询的可及性，对低教育程度人群的改善程度高于高教育程度人群。
