Healthcare inequalities in general practice due to educational level: A retrospective cohort study analysing patients' presentation and GP response to requests.

Abstract

BACKGROUND: Educational level is an important social determinant of health and may contribute to healthcare inequity by affecting how patients present health problems. OBJECTIVES: Explore the interaction between patients' educational level (1), their presentation of health problems to general practitioners (GPs) and (2) GP's responses to requested interventions. DESIGN AND SETTING: Retrospective cohort study within a Dutch primary care practice-based research network. METHODS: All new episodes of care of patients' aged ≥25 years between 2014 and 2022 were included. Data were collected on the reason for encounter (RFE) at initial contact within each episode, and patients' educational level. Differences were analysed in incidence of RFE types (symptoms, intervention-requests, self-diagnoses) and GP's policies regarding requested diagnostic and therapeutic interventions among patients with low, medium and high educational levels. RESULTS: Patients with lower educational levels more frequently presented symptoms (59.7% versus 56.5%) and were less likely to present with intervention requests (OR 0.88) or self-diagnosis (OR 0.83). They requested more urine tests (RR 1.28), but fewer blood tests (RR 0.90), diagnostic imaging (RR 0.75) and referrals to primary (RR 0.74) and secondary care (RR 0.87). GPs responded more often to urine test requests (RR 1.25), but less often to referral requests to primary (RR 0.68) and secondary care (RR 0.80) among patients with lower educational levels. CONCLUSION: This study emphasises GPs' need to understand how educational status affects patient's presentation and intervention preferences, which can improve communication, shared decision-making and enhance equitable healthcare delivery by addressing an important social determinant of health.