In the UK, the number of people living with multiple long-term conditions is rising. This is concerning because those with multiple conditions have higher treatment burden, reduced quality of life and higher risk of mortality. It also has serious implications for the NHS because of the link between multiple conditions and use of primary and secondary care services.
Local studies suggest that people from minoritised ethnic groups have a greater risk of multiple long-term conditions than the white majority population. Many have faced experiences of racial discrimination and socioeconomic disadvantage throughout life. These experiences likely increase their risk of multiple conditions. They are also more likely to develop multiple conditions at a younger age. Further, stark ethnic inequalities in COVID-19 infection and mortality have been documented by the ONS, with pre-existing conditions being one of the contributing factors to this. Despite this, there is an incomplete picture of ethnic differences in the prevalence, healthcare utilisation and care quality for people with multiple conditions in the UK.
This study aims to provide novel information on ethnic inequalities in healthcare utilisation and quality in people with multiple conditions and some of the factors that may underlie these inequalities. It also seeks to illuminate ethnic differences in changes in healthcare utilisation since the start of the pandemic. The findings will contribute to the evidence base to inform health system leads about the care needs of minoritised ethnic group populations and highlight where care could be improved, and ethnic inequalities addressed.
This study aims to
Provide an up-to-date description of how multiple conditions vary across ethnic groups in the UK;
Describe ethnic differences in healthcare utilisation and indicators of care quality for people with multiple conditions before the pandemic;
Describe ethnic differences in healthcare utilisation during the pandemic compared with 3-year average.
It uses CPRD data from 2016 to examine multiple conditions diagnosed in primary care, by ethnic group. Multimorbidity is defined as the presence of two or more long-term conditions likely to lead to poor quality of life, significant need for treatment or greater risk of premature death (1,2). Level (number of conditions) and type of multimorbidity (e.g. complex multimorbidity) will be considered.
To estimate the prevalence of multimorbidity by ethnic group, sex, age and socioeconomic deprivation, linked ONS IMD data will be used. To examine the full patient pathway, linked HES data on Admitted patient care, Outpatient care and Accident and Emergency and ONS mortality data care will be used.
Number of primary and secondary care visits by ethnicity will be estimated in poisson regression models (or logistic regression models for rarer outcomes). Models will sequentially adjust for i) sex and age, ii) indicators of need for health care (number of long-term conditions, combination of conditions and time since onset of multimorbidity), and iii) indicators of social need (area deprivation quintile). Given the structural inequalities leading to an association between ethnic minority status and deprivation within the UK, deprivation is included as a possible mediating factor. Where sample size allows, inequalities in healthcare at the intersection of gender, age and ethnicity will be modelled.
The main analysis will use pre-pandemic data (to end December 2019). Utilisation by ethnic group during and pre-pandemic will also be estimated in regression models.
Outcomes of interest will be derived from CPRD and linked HES and ONS Death registration data. Multimorbidity is not limited to physical health conditions and can also include mental health conditions. Previous work highlights depression and severe mental health among the most common conditions diagnosed first in people with multiple long term health conditions (3). We will, therefore, include use of mental health care as well as overall care use in our investigations.
Outcomes capturing multimorbidity level and type:
Whether patient has two or more conditions
Number of conditions
Whether patient has complex multimorbidity (with conditions in more than one body system)
Outcomes capturing care utilisation:
Number of primary care consultations
Number of prescribed products (total and psychiatric products)
Number of immunisations administered
Number of medical tests requested
Number and duration of hospital admissions (total and mental-health related)
Number of outpatient visits (total and mental-health related);
Number of emergency department visits (total and mental-health related)
Outcomes that may indicate aspects of care quality:
Continuity of care in primary care
Number of hospital admissions for an ambulatory care sensitive condition
30-day hospital readmission
All-cause mortality
Personal care adjustment (previously QOF exception reporting)
Mai Stafford - Chief Investigator - The Health Foundation
Yannis Kotrotsios - Corresponding Applicant - The Health Foundation
Alexander Lawless - Collaborator - The Health Foundation
Andrew Mooney - Collaborator - The Health Foundation
Anne Alarilla - Collaborator - The Health Foundation
Brenda Hayanga - Collaborator - University of Sussex
George Stevenson - Collaborator - The Health Foundation
Jay Hughes - Collaborator - The Health Foundation
Laia Becares - Collaborator - University of Sussex
Yannis Kotrotsios - Collaborator - The Health Foundation
Catherine Saunders - Collaborator - University of Cambridge
HES Accident and Emergency;HES Admitted Patient Care;HES Outpatient;ONS Death Registration Data;Patient Level Index of Multiple Deprivation