Adult Immigrants’ Utilization of Physician Visits, Dentist Visits, and Prescription Medication

Do changes in primary care service use over time differ by neighbourhood income? Population-based longitudinal study in British Columbia, Canada

Background

Strong primary care systems have been associated with improved health equity. Primary care system reforms in Canada may have had equity implications, but these have not been evaluated. We sought to determine if changes in primary care service use between 1999/2000 and 2017/2018 differ by neighbourhood income in British Columbia.

Methods

We used linked administrative databases to track annual primary care visits, continuity of care, emergency department (ED) visits, specialist referrals, and prescriptions dispensed over time. We use generalized estimating equations to examine differences in the magnitude of change by neighbourhood income quintile, adjusting for age, sex/gender, and comorbidity, and stratified by urban/rural location of residence. We also compared the characteristics of physicians providing care to people living in low- and high-income neighbourhoods at two points in time.

Results

Between 1999/2000 and 2017/8 the average number of primary care visits per person, specialist referrals, and continuity of care fell in both urban and rural settings, while ED visits and prescriptions dispensed increased. Over this period in urban settings, primary care visits, continuity, and specialist referrals fell more rapidly in low vs. high income neighbourhoods (relative change in primary care visits: Incidence Rate Ratio (IRR) 0.881, 95% CI: 0.872, 0.890; continuity: partial regression coefficient -0.92, 95% CI: -1.18, -0.66; specialist referrals: IRR 0.711, 95%CI: 0.696, 0.726), while ED visits increased more rapidly (IRR 1.06, 95% CI: 1.03, 1.09). The percentage of physicians who provide the majority of visits to patients in neighbourhoods in the lower two income quintiles declined from 30.6% to 26.3%.

Conclusion

Results raise concerns that equity in access to primary care has deteriorated in BC. Reforms to primary care that fail to attend to the multidimensional needs of low-income communities may entrench existing inequities. Policies that tailor patterns of funding and allocation of resources in accordance with population needs, and that align accountability measures with equity objectives are needed as part of further reform efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01679-4.

Theoretical evidence explaining the relationship between socio-demographic and psychosocial barriers on access to oral health care among adults: A scoping review

OBJECTIVES

Current global models for oral health care are outdated. Out of pocket payments and exclusion from most national health systems has created a gap for access of services by socio-economically vulnerable adults. Our objective is to understand barriers to access and the causal associations between barriers to care.

DATA

All study designs with a theoretical/conceptual framework to explain access and barriers among adults were included.

SOURCES

6 electronic databases (PubMed, Medline (EBSCO), CINAHL, Embase, Web of Science) including grey literature searches (ProQuest) and expert consultation. The identified studies were then analysed using narrative synthesis and NVivo.

STUDY SELECTION/RESULTS

40 studies using a theoretical framework to explain access among adults were identified. Andersen's behavioural model was most used. Cost was the primary causal factor that perpetuated the effect of other barriers. Associations were found between age and education level, cost and need, cost and dental anxiety. Study design and analysis used to identify these associations had limitations in determining causality.

CONCLUSION

Oral health access research is based in theory, leading to the identification of socio-demographic and psychosocial barriers and their relationships. However, a lack of explanation of causal associations persists. This review recognises the importance of understanding the cause of barriers in addition to their nature. Appropriate study designs and analysis considering the impact of time varying factors on access is required. Empirical analysis needs to focus on the role of confounders and mediators to determine causality successfully. To achieve this a theory driven causal model has been proposed.