Does use of GP and specialist services vary across areas and according to individual socioeconomic position? A multilevel analysis using linked data in Australia.

OBJECTIVE: Timely access to primary care and supporting specialist care relative to need is essential for health equity. However, use of services can vary according to an individual's socioeconomic circumstances or where they live. This study aimed to quantify individual socioeconomic variation in general practitioner (GP) and specialist use in New South Wales (NSW), accounting for area-level variation in use. DESIGN: Outcomes were GP use and quality-of-care and specialist use. Multilevel logistic regression was used to estimate: (1) median ORs (MORs) to quantify small area variation in outcomes, which gives the median increased risk of moving to an area of higher risk of an outcome, and (2) ORs to quantify associations between outcomes and individual education level, our main exposure variable. Analyses were adjusted for individual sociodemographic and health characteristics and performed separately by remoteness categories. SETTING: Baseline data (2006-2009) from the 45 and Up Study, NSW, Australia, linked to Medicare Benefits Schedule and death data (to December 2012). PARTICIPANTS: 267 153 adults aged 45 years and older. RESULTS: GP (MOR=1.32-1.35) and specialist use (1.16-1.18) varied between areas, accounting for individual characteristics. For a given level of need and accounting for area variation, low education-level individuals were more likely to be frequent users of GP services (no school certificate vs university, OR=1.63-1.91, depending on remoteness category) and have continuity of care (OR=1.14-1.24), but were less likely to see a specialist (OR=0.85-0.95). CONCLUSION: GP and specialist use varied across small areas in NSW, independent of individual characteristics. Use of GP care was equitable, but specialist care was not. Failure to address inequitable specialist use may undermine equity gains within the primary care system. Policies should also focus on local variation.

Using predictive risk modelling to identify patients with hidden health needs in an Aboriginal and Torres Strait Islander health service.

BACKGROUND AND OBJECTIVES: In partnership with an Aboriginal and Torres Strait Islander community-controlled health service, we explored the use of a machine learning tool to identify high-needs patients for whom services are harder to reach and, hence, who do not engage with primary care. METHOD: Using deidentified electronic health record data, two predictive risk models (PRMs) were developed to identify patients who were: (1) unlikely to have health checks as an indicator of not engaging with care; and (2) likely to rate their wellbeing as poor, as a measure of high needs. RESULTS: According to the standard metrics, the PRMs were good at predicting health checks but showed low reliability for detecting poor wellbeing. DISCUSSION: Results and feedback from clinicians were encouraging. With additional refinement, informed by clinic staff feedback, a deployable model should be feasible.

Aboriginal and Torres Strait Islander community members' experiences of care in an urban Aboriginal Community Controlled Health Service transforming to a Patient Centred Medical Home.

Background Few studies have examined patient experiences of the Patient Centred Medical Home (PCMH). This qualitative study explores the experiences of patients of an urban Aboriginal Community Controlled Health Service during its transition to a model of a PCMH. Methods Twenty-eight community members who were registered as patients of an urban Aboriginal Community Controlled Health Service were purposively recruited to participate in yarning interviews. Yarns were conducted using a guide containing open-ended questions in the same domains as those used in patient satisfaction surveys at the participating clinic. Data from yarns were analysed by Aboriginal and non-Indigenous researchers using thematic analysis. The interpretations of Aboriginal and Torres Strait Islander researchers were privileged in the analysis. Results Key themes highlighted the importance of relationships, connectedness, and personal growth and empowerment to community members' health and wellbeing, which they described as a journey of healing and recovery. Delays in implementing a process to empanel patients in a care team meant that most community members were unaware a PCMH had been implemented. However, community members commonly reported a more welcoming environment, more contact with the same doctor and more involvement of Aboriginal Health Workers in their care. Conclusions Aboriginal and Torres Strait Islander community members' narratives of their experiences bear evidence of the acceptability of a PCMH model for delivery in Aboriginal Community Controlled Health Services to improve relational care between patients and health staff. A patient-directed empanelment process has been implemented to better connect patients to their care team in the clinic, and the role of the Aboriginal Health Worker reshaped to strengthen connections between patients and their care team in and outside the clinic.