Background There has been increasing research interest in the adverse effects of public health interventions; notably concern that processes in the planning or delivery of an intervention may create or exacerbate the health differences between population groups. The aim of this study was to contribute to current understanding of ‘intervention-generated inequalities’ by examining the impact of secondary and tertiary preventive interventions for Type 2 diabetes by socio-economic status (SES). Previous research has shown that Type 2 diabetes places a disproportionate health burden on individuals from more disadvantaged backgrounds. It addition, managing the condition involves multiple processes and health professionals, all of which all could potentially exacerbate existing health inequalities.
Methods A secondary data analyses of patient level data collected by a hospital trust diabetes register from 1999 to 2007 was conducted to determine if receiving the same care was associated with differential health outcomes by SES. Two indicators of care were used: the number of recommended care processes (quality of care) and attendance at a hospital diabetes care clinic (shared care) each year. The Index of Multiple Deprivation 2004 was used as an indicator of patients’ SES. A series multilevel models were fitted with hbA1c, an indicator of patient’s diabetes control, as the dependent variable with interaction effects between SES and intervention indicators. Repeated measurements were nested within patients, nested within the general practice they registered with per year. Relevant socio-demographic, anthropometric, lifestyle, health and other intervention data controlled for in each model.
Results The initial descriptive analyses showed that high SES was statistically significantly receive greater quality of care and less likely to receive shared care than low SES patients. Overall, in both multilevel models high SES patients were more like more favourable hbA1c rates than low SES patients. However the interaction effects suggest that amongst patients receiving high quality of care, high SES patients were significantly more likely to have poorer HbA1c compared to low SES patients. In contrast amongst patients receiving shared care, high SES patients were more likely to have more favourable HbA1c rates than low SES patients.
Discussion There was evidence that low SES patients received a poor quality of care but had greater access to specialist, secondary care. In addition, there was evidence to suggest that patients receiving the same care were associated with a differential impact on patients HbA1c. More complex analyses need to be conducted to determine the direction of these associations.
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