Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations

Abstract

PURPOSEThe influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation. METHODSWe conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP's empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups. RESULTSIn affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727). CONCLUSIONSIn deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care.

The inverse care law revisited: a continuing blot on the record of the National Health Service

“…[7][8][9] Although affluent patients with multimorbidity get 25% longer consultations, similar patients in deprived areas get no additional time. 10 The consequences are unmet need, poorly coordinated care, and greater reliance on unscheduled care services -modern manifestations of the inverse care law.…”

Improving identification and management of familial hypercholesterolaemia in primary care: Pre- and post-intervention study

“…The lower uptake of eligible patients with elevated cholesterol was also due to purposeful recruitment in areas of low deprivation (4/6 practices). It is recognised that patients from these deprived UK areas may face greater challenges in engaging with preventive and primary health care in the context of multiple morbidities and competing health and other life priorities [26].…”

Primary care consultation length by deprivation and multimorbidity in England

“…Despite these recommendations, research in Scotland has shown that the greater need of patients with multimorbidity living in the most deprived quarter of areas is not reflected in longer consultation length. This is in contrast to the least deprived quarter of areas where those with multimorbidity received longer consultations than those without (14). This is an example of the inverse care law, where the availability of good medical care tends to vary inversely with need.…”

“…Deprivation was based on the patient's area of residence (Lower Super Output Area level) using deciles of the 2015 Index of Multiple Deprivation (14), grouped into high deprivation (deciles 1-3), medium deprivation (4-7) or low deprivation (8)(9)(10). Linkage was undertaken by CPRD.…”