Background Ill health and relative poverty are connected. This study aimed to determine first whether the worse health experienced by poorer participants was matched by appropriately greater receipt of healthcare, and second whether any inequalities in receipt occurred at the stage of diagnosis or treatment.
Methods The English Longitudinal Study of Ageing is a cohort of participants aged 50 years or older. The relative distributions by wealth of symptoms, diagnosis and treatment of five common chronic conditions (angina, diabetes, depression, osteoarthritis, and cataract) were analysed in four waves of data collected from 2002 to 2010. Symptoms were defined for angina using the Rose Angina scale, diabetes using fasting HbA1c level, depression using the Centre for Epidemiologic Studies Depression Scale, osteoarthritis as self-reported pain and disability, and cataract as self-reported poor vision. Doctors’ diagnoses for all conditions were self-reported. Treatment was defined for angina as beta-blocker prescription, osteoarthritis and cataract as surgery, and diabetes and depression as receiving treatment described in quality indicators. Binomial regression models tested variations between the hypothetically poorest and richest individuals for age and sex adjusted symptoms, diagnosis and treatment across the waves, using a slope index of inequality.
Results Symptoms were commoner in poorer participants in all 5 conditions at all 4 timepoints, with ORs ranging from 2.5 to 7.0. In angina, depression and diabetes, receipt of diagnosis and treatment was similarly higher in poorer participants, with ORs ranging from 1.9 to 5.6. In osteoarthritis and cataract, receipt of diagnosis and treatment did not show substantial matching variations by wealth, with ORs ranging from 0.8 to 1.9. For example, ORs for diabetes in 2008 were broadly similar for symptoms (2.5 [95% CI 1.5, 4.0], diagnosis (3.8 [3.0, 4.9]) and treatment (3.1 [2.4, 4.0]). In contrast, osteoarthritis ORs were substantially larger for symptoms (6.9 [5.2, 9.1]) than for diagnosis (1.4 [1.2, 1.7]) or treatment (0.8 [0.5, 1.3]).
Conclusion Poorer participants were much more likely to have symptoms of osteoarthritis and cataract, but not much more likely to receive a diagnosis. The block in equitable receipt of healthcare was at the stage of diagnosis rather than treatment, and so interventions to reduce inequalities in osteoarthritis and cataract should focus on the diagnostic process. The same relative inequalities in diagnosis were not seen in angina, depression and diabetes, which have all been the target of multiple quality improvement initiatives. These patterns remained consistent over 8 years.
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