1. Ethnic inequalities in access to and
outcomes of healthcare
James Nazroo
Sociology, School of Social Sciences
james.nazroo@manchester.ac.uk
Emanuela Falaschetti, Mary Pierce and Paola Primatesta
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r
Department of Epidemiology, UCL

2. Background
• Large body of evidence from the US demonstrating racial/ethnic inequalities
in access to health care and outcomes of health care.
• Insurance status is a key (but not the only) determinant of these.
• US healthcare systems with universal access (military and veterans Affairs)
appear to have fewer inequalities.
• But evidence from the NHS, although limited, also suggests inequalities:
• Greater use of primary care is not matched by greater use of secondary care;
• Higher levels of dissatisfaction with care received;
• Longer waits for appointments;
• Poorer quality of practice infrastructure;
• Language barriers during the consultation;
• Less likely to get follow up services after initial consultation;
• Longer waits for referral to specialist care;
• Less likely to receive specialist treatments (revascularisation and thrombolysis).
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

3. Objectives
• Examine ethnic inequalities in access to health care:
• Primary care (GP and Dentist);
• Out- and day-patient hospital care;
• In-patient care.
• Examine ethnic inequalities in the outcomes of care received for:
• Hypertension
• Raised cholesterol
• Diabetes
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

4. Methods: sample and data collection
• Health Survey for England, ethnic minority (1999 and 2004) and
cardiovascular (1998 and 2003) years
• Those aged 16-74
• Nationally representative samples (but does not include ethnic minority people
living in very low density areas)
• Stratified (NHS regions and socioeconomic profiles) and clustered sample
• Addresses identified using the Postcode Address File (except the Chinese sample)
• Ethnic minority sample also stratified according to Census data on ethnic density
• Response rates vary by ethnicity (individual rate 60-70%)
• Ethnicity classified according to family origins
• Gives a large sample of Irish, Black Caribbean, Indian, Pakistani, Bangladeshi
and Chinese respondents
• Language matched interviewers
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

5. Methods: measures for access
• Visited a GP for consultation in the last two weeks (HSE 1999 only)
• Been an in-patient (stayed overnight or longer) in the last year
• Attended a hospital as an out- or day-patient in the last year
• Have regular or occasional check-ups with a dentist (HSE 1999 only)
• Analysis using stata and accounting for sample weights (to adjust for
unequal probabilities of selection) and for the stratification and
clustering of the sample
• Models initially adjusted for age and gender; then for self-assessed
health and limiting longstanding illness
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

6. Visited a GP in the last two weeks
(odds ratio compared with white English, adjusted for age and gender)
2.2
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
Irish Caribbean Indian Pakistani Bangladeshi Chinese
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

7. Visited a GP in the last two weeks
(odds ratio and 95% c.i., compared with white English)
2.2 2.2
Adjusted for age and gender only + self-reported health and limiting longstanding illness
2.0 2.0
1.8 1.8
1.6 1.6
1.4 1.4
1.2 1.2
1.0 1.0
0.8 0.8
0.6 0.6 h
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C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

8. In-patient in the last year
(odds ratio and 95% c.i., compared with white English)
1.8 1.8
Adjusted for age and gender only + self-reported health and limiting longstanding illness
1.6 1.6
1.4 1.4
1.2 1.2
1.0 1.0
0.8 0.8
0.6 0.6
0.4 0.4
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C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

9. Out or day-patient in the last year
(odds ratio and 95% c.i., compared with white English)
1.4 1.4
Adjusted for age and gender only + self-reported health and limiting longstanding illness
1.2 1.2
1.0 1.0
0.8 0.8
0.6 0.6
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C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

10. Visit dentist at least occasionally
(odds ratio and 95% c.i., compared with white English)
1.2 1.2
Adjusted for age and gender only + self-reported health and limiting longstanding illness
1.0 1.0
0.8 0.8
0.6 0.6
0.4 0.4
0.2
0.2
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0.0
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C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

11. Hypertension (measured BP ≥ 140/90 or diagnosed)
(odds ratio compared with white English, adjusted for age and gender)
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
Irish Caribbean Indian Pakistani Bangladeshi Chinese
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

12. Raised cholesterol (≥ 5.0mmol/l or diagnosed)
(odds ratio compared with white English, adjusted for age and gender)
1.2
1.0
0.8
0.6
0.4
Irish Caribbean Indian Pakistani Bangladeshi Chinese
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

13. Diabetes (HbA1c ≥ 6.5% or diagnosed)
(odds ratio compared with white English, adjusted for age and gender)
20
15
10
5
0
Irish Caribbean Indian Pakistani Bangladeshi Chinese
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

14. Methods: measures for outcome of care
• Hypertension (diagnosed or measured ≥ 140/90)
• Hypertensive controlled: BP < 140/90 but report diagnosis or treatment
• Hypertensive uncontrolled: BP ≥ 140/90 and report diagnosis or treatment
• Hypertensive undiagnosed: BP ≥ 140/90, but no report of diagnosis or treatment
• Raised total cholesterol (diagnosed or measured ≥ 5mmol/l)
• Controlled: cholesterol < 5 mmol/l but report diagnosis or treatment
• Raised uncontrolled: cholesterol ≥ 5mmol/l and report diagnosis or treatment
• Raised undiagnosed: cholesterol ≥ 5mmol/l, but no report of diagnosis or
treatment
• Diabetes (diagnosed or measured HbA1c > 6.5%)
• Diabetic controlled: HbA1c ≤ 7.5% with report of diagnosis or treatment
• Diabetic uncontrolled: HbA1c > 7.5% and report diagnosis or treatment
• Diabetic undiagnosed: HbA1c indicative of diabetes (> 6.5%) not diagnosed or
treated
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

15. Treatment outcomes for those with hypertension
multinomial regression relative risks compared with ‘controlled’ and white English
Uncontrolled Undiagnosed
1.4 1.4
1.2 1.2
1.0 1.0
0.8 0.8
0.6 0.6
0.4 0.4
0.2 0.2
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C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r Model adjusted for estimated CVD risk (Framingham) and income

16. Treatment outcomes for those with raised cholesterol
multinomial regression relative risks compared with ‘controlled’ and white English
Uncontrolled Undiagnosed
1.4 1.4
1.2 1.2
1.0 1.0
0.8 0.8
0.6 0.6
0.4 0.4
0.2 0.2
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C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r Model adjusted for estimated CVD risk (Framingham) and income

17. Treatment outcomes for those with diabetes
multinomial regression relative risks compared with ‘controlled’ and white English
Uncontrolled (HbA1c > 7.5%) Undiagnosed (HbA1c > 6.5%)
3.0 3.0
2.5 2.5
2.0 2.0
1.5 1.5
1.0 1.0
0.5 0.5
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C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r Model adjusted for estimated CVD risk (Framingham) and income

18. Conclusions (1)
• No inequalities in access to GP services
• No inequalities in outcomes of care for hypertension, raised
cholesterol and, possibly, diabetes
• Some inequalities in access to hospital services (particularly use of
out- and day-patient services)
• Marked inequalities in access to dental services
• Limited subset of (important) conditions – contrary findings for other
conditions and for reported levels of satisfaction with care received
• Conditions largely managed in primary care settings
• Response rates, sample size and power
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r

19. Conclusions (2)
• Marked similarities between the US and UK in terms of ethnic
inequalities in health and socioeconomic position
• Marked differences in terms of access to and outcomes of healthcare
• The effect of differences in healthcare systems – a health service with
universal access?
• But discrepancy between primary care and secondary care in
England
• Differences in thresholds triggering primary care consultation (lack of
evidence)
• Differences in thresholds for referral by practitioners (contradictory
evidence)
• Use of private care (some limited evidence)
C om b ining th e s tre ngth s of U M IS T and
Th e Victoria U nive rs ity o f M anch e s te r