Ethnic inequities in the patterns of Personalised Care Adjustments for ‘Informed Dissent’ and ‘Patient Unsuitable’: A retrospective study using Clinical Practice Research Datalink

Problem

General Practitioners in England voluntarily take part in the Quality and Outcomes Framework (QOF)– a programme to resource and reward good practice. Some patients receive a personal care adjustment (PCA) which excludes them from the statistics for this programme because they are considered ‘unsuitable’ (e.g. if they have complex care needs that require a different approach to treatment) or because they opt not to have the treatment/intervention offered. Patients who are older, living in deprived areas, and have multiple long-term conditions are more likely to have a PCA. Minoritised ethnic group people may be more likely to have PCAs as they are disproportionately represented in the most deprived areas and have as many or more long-term conditions than white people. We have a partial understanding of ethnic inequities in PCAs because prior studies have aggregated ethnic group populations, focused on specific conditions, or combined all PCA reasons. This study examines patterns of PCA reporting for ‘informed dissent’ and ‘patient unsuitable’, how they vary by ethnic group, and whether ethnic inequities can be explained by socio-demographic factors or comorbidities.

Approach

This retrospective study uses individual patient data from Clinical Practice Research Datalink. The sample consists of patients aged 18+ years on the 1st of January 2016, with at least one of the 12 QOF conditions with PCA coding options, from a random sample of 690,00 patients. The associations between ethnicity and two PCA reasons (‘Informed Dissent’ and ‘Patient Unsuitable’) were examined using logistic regressions after adjustment for age, sex, multiple QOF conditions and area-level deprivation.

Findings

The association between ethnicity and the two PCA reasons were in opposite directions. After accounting for age, gender, multiple QOF conditions and area-level deprivation, people of Bangladeshi [OR: 0.69, 95% CI: 0.55 to 0.87], Black African [OR: 0.70, 95% CI: 0.61 to 0.81], Black Caribbean, OR: 0.67, 95% CI: 0.58 to 0.76], Indian [OR: 0.74, 95% CI: 0.66 to 0.83], mixed [OR: 0.86, 95% CI: 0.74 to 0.99], other Asian [OR: 0.74 95% CI: 0.64 to 0.86] and other ethnicity [OR: 0.66, 95% CI: 0.55 to 0.80] were less likely to have a PCA record for ‘informed dissent’ than people of white ethnicity. Only people of Indian ethnicity were significantly less likely than people of white ethnicity to have a PCA record for ‘patient unsuitable’ in fully adjusted models [OR: 0.80, 95% CI: 0.67 to 0.94]. We found ethnic inequities in PCA reporting for ‘patient unsuitable’ among people of Black Caribbean, Black other, Pakistani, and other ethnicity, but these attenuated after adjusting for multiple QOF conditions and/or area-level deprivation.

Consequences

Study findings counter the narratives that suggest that people from minoritised ethnic groups often refuse medical intervention. They illuminate the complex relationship between ‘informed dissent’ and (dis)empowerment which requires further scrutiny. They also show ethnic inequalities in PCA reporting for ‘patient unsuitable’ that are linked to clinical and social complexity and should be tackled to improve health outcomes for all.