Association of the Social Determinants of Health With Quality of Primary Care

Alan Katz; Dan Chateau; Jennifer E. Enns; Jeff Valdivia; Carole Taylor; Randy Walld; Scott McCulloch

doi:10.1370/afm.2236

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Figure 1
Prevalence of individual social complexity factors and distribution of patients according to number of factors.
Notes: Analyses based on entire study cohort (N = 626,264), except for teen mother (restricted to female patients, N = 332,542); in care of Child Welfare Services (restricted to youth ≤18 y, N = 134,415); and child of a newcomer (restricted to newcomers ≤18 y, N = 125,624). See Methods for definitions of social complexity factors.

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Table 1

Characteristics of the Study Cohort (N = 626,264)

Characteristic	Patients, No. (%)
Sex
Male	293,722 (46.9)
Female	332,542 (53.1)
Age, y
0–5	49,422 (7.9)
6–18	84,973 (13.6)
19–44	231,096 (36.9)
45–64	177,176 (28.3)
65–74	44,273 (7.1)
≥75	39,304 (6.3)
Income^a
Q1 ($14,772–$49,509)	127,638 (20.4)
Q2 ($49,510–$63,661)	121,591 (19.4)
Q3 ($63,662–$79,531)	119,853 (19.1)
Q4 ($79,532–$98,953)	127,495 (20.4)
Q5 ($98,954–$343,154)	122,731 (19.6)
Unknown	6,956 (1.1)
Morbidity (RUB)
0–1	153,480 (24.5)
2	204,545 (32.7)
3	236,016 (37.7)
4–5	32,223 (5.1)

Q = quintile; RUB = resource utilization band.
↵a In 2013 Canadian dollars.

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Table 2

Association of Social Complexity Factors With Indicators of the Quality of Primary Care

Quality Indicator	Likelihood of Receipt, Odds Ratio (99% CI)^a					P Value^b

	1 Factor	2 Factors	3 Factors	4 Factors	≥5 Factors
Prevention and screening
Breast cancer screening (women 50–74 y)	0.77 (0.73–0.81)	0.54 (0.50–0.58)	0.38 (0.34–0.42)	0.28 (0.24–0.33)	0.22 (0.18–0.27)	<.001
Cervical cancer screening (women 21–69 y)	1.04 (1.00–1.08)	0.96 (0.92–1.01)	0.87 (0.81–0.92)	0.94 (0.87–1.02)	1.01 (0.93–1.09)	.003
Colorectal cancer screening (adults 50–74 y)	0.83 (0.80–0.86)	0.66 (0.63–0.70)	0.51 (0.47–0.56)	0.40 (0.35–0.46)	0.36 (0.30–0.44)	.001
Completed vaccinations at 2 y	0.70 (0.61–0.81)	0.55 (0.46–0.66)	0.41 (0.33–0.50)	0.33 (0.26–0.43)	0.26 (0.19–0.36)	<.001
Annual influenza vaccination (adults ≥65 y)	0.88 (0.83–0.93)	0.74 (0.68–0.82)	0.69 (0.59–0.81)	0.68 (0.52–0.89)	1.17 (0.76–1.79)	<.001
Annual influenza vaccination (total respiratory morbidity)	0.84 (0.80–0.87)	0.75 (0.70–0.79)	0.74 (0.69–0.80)	0.67 (0.61–0.74)	0.64 (0.58–0.71)	.02
Pneumococcal vaccination (adults ≥65 y)	0.95 (0.90–1.01)	0.88 (0.80–0.97)	0.90 (0.76–1.07)	0.90 (0.69–1.18)	0.90 (0.59–1.39)	.001
Chronic disease management
Diabetes management: eye examination	0.86 (0.79–0.92)	0.78 (0.70–0.87)	0.70 (0.61–0.82)	0.69 (0.58–0.84)	0.52 (0.42–0.64)	<.001
CHF management: initiation of ACE inhibitor	0.90 (0.73–1.11)	0.72 (0.53–0.99)	0.80 (0.50–1.29)	0.59 (0.32–1.09)	0.41 (0.19–0.88)	<.001
CHF management: persistence of ACE inhibitor	0.85 (0.69–1.05)	0.77 (0.56–1.05)	0.63 (0.39–1.01)	0.74 (0.40–1.36)	0.27 (0.11–0.63)	.045
Post-MI management: initiation of β-blocker	1.16 (0.76–1.77)	0.80 (0.45–1.43)	0.96 (0.39–2.37)	0.30 (0.12–0.76)	0.48 (0.14–1.67)	.04
Post-MI management: persistence of β-blocker	0.97 (0.72–1.31)	0.77 (0.50–1.19)	0.75 (0.40–1.39)	0.66 (0.29–1.52)	0.94 (0.34–2.66)	.65
Post-MI management: initiation of statin	0.87 (0.64–1.17)	0.81 (0.52–1.25)	0.63 (0.34–1.19)	0.43 (0.19–0.98)	0.91 (0.31–2.69)	.02
Post-MI management: persistence of statin	0.75 (0.56–1.01)	0.76 (0.49–1.16)	0.49 (0.26–0.92)	0.46 (0.20–1.05)	0.82 (0.30–2.24)	.004
Asthma management: medication use	0.90 (0.82–0.99)	0.90 (0.80–1.01)	0.81 (0.71–0.94)	0.81 (0.69–0.96)	0.88 (0.75–1.04)	.001
Medications
Benzodiazepine prescription (community-dwelling adults ≥75 y)	1.63 (1.48–1.80)	2.16 (1.82–2.56)	3.15 (2.25–4.40)	3.03 (1.36–6.71)	3.08 (0.68–14.00)	<.001
Beers List drug prescription (community-dwelling adults ≥65 y)	1.39 (1.31–1.47)	1.92 (1.74–2.12)	2.37 (2.01–2.79)	3.50 (2.67–4.60)	4.05 (2.61–6.28)	<.001
Depression care: prescription follow-up	1.07 (0.90–1.28)	1.09 (0.88–1.35)	1.09 (0.83–1.42)	1.21 (0.89–1.64)	1.46 (1.08–1.99)	.004
Health services use
Hospitalizations for ACSC (adults ≥74 y)	1.43 (1.11–1.84)	2.40 (1.77–3.24)	3.58 (2.52–5.08)	4.80 (3.24–7.11)	5.64 (3.70–8.60)	<.001
Radiograph for low back pain (adults ≥20 y)	0.92 (0.73–1.15)	1.02 (0.76–1.37)	0.80 (0.54–1.18)	0.83 (0.50–1.37)	1.10 (0.68–1.80)	.34
Hospital episodes with readmission within 30 d	1.23 (1.11–1.36)	1.41 (1.25–1.60)	1.86 (1.62–2.15)	1.91 (1.63–2.24)	2.21 (1.89–2.58)	<.001
ED visits for low-acuity (CTAS 4 and 5^c) patients	1.21 (1.17–1.24)	1.54 (1.50–1.60)	2.02 (1.95–2.10)	2.61 (2.51–2.72)	3.38 (3.24–3.51)	<.001
Ambulatory visits to primary care	1.09 (1.08–1.09)	1.19 (1.19–1.20)	1.29 (1.28–1.29)	1.41 (1.40–1.42)	1.62 (1.61–1.62)	.001
Ambulatory visits for patients with RUB of 3, 4, or 5	1.11 (1.09–1.13)	1.26 (1.23–1.29)	1.44 (1.36–1.51)	1.70 (1.55–1.86)	2.12 (1.88–2.39)	<.001
Ambulatory visits with a call to health telephone service within 2 d of visit	1.02 (0.97–1.06)	1.14 (1.08–1.20)	1.33 (1.25–1.42)	1.53 (1.43–1.64)	1.75 (1.63–1.87)	<.001

ACE = angiotensin-converting enzyme; ACSC = ambulatory care–sensitive conditions; CHF = congestive heart failure; CTAS = Canadian Triage Acuity Scale; ED = emergency department; MI = myocardial infarction; RUB = resource utilization band.
Note: Adjusted for sex, age, income quintile, and morbidity level (RUB).
↵a Compared with patients having no social complexity factors.
↵b For trend across factor categories.
↵c On a scale of 1 to 5, with 5 being lowest acuity.