Using socioeconomic evidence in clinical practice guidelines

The article by Aldrich et al(1) makes the important point that
socioeconomic inequalities are likely to occur at all points along the
pathway of care, from needs assessment to compliance with clinical
recommendations – and not just in terms of the availability of primary
care, as discussed by Julian Tudor Hart in his famous paper on the
‘Inverse Care Law’.(2)

The authors state that “literature describing interventions that
attempt to overcome barriers to achieving equal health outcomes is often
scarce.” However, the problem is not just the scarcity of literature on
methods of overcoming socioeconomic variations in health, but the lack of
clear evidence on the effectiveness of different interventions across the
socioeconomic spectrum. Whilst there is some evidence that interventions
are differentially effective according to socioeconomic position(3) and it
seems likely that this will be the case across the board,(4) there is
little good quality evidence to confirm this.

Aldrich et al go on to suggest that in the absence of good quality
evidence on the best methods to “overcome [socioeconomic] barriers to
achieving equal health outcomes…the general principles of equitable
service” should be applied. Whilst these general principles are laudable,
they are vague in terms of what should be specifically recommended to
practitioners. Furthermore, there is little evidence that applying these
principles will result in appreciable effects overall on socioeconomic
variations in health status.

Developing clinical practice guidelines which take socioeconomic
position into account is likely to be an important step towards reducing
socioeconomic variations in health. However, the framework proposed by
Aldrich et al will result in vague recommendations, based on minimal
evidence, which practitioners will find hard to implement. What is
required is a concerted programme of research to investigate the effects
of a wide variety of interventions on socioeconomic variations in health.
This should involve systematic reviews with an equity focus, reanalysis of
existing outcome data to investigate variability in effectiveness of
interventions according to socioeconomic position and specific
investigation of interventions which do not appear to widen socioeconomic
variations to determine what aspects of these interventions can be more
widely applied and to whom. In addition, investigators should be
encouraged to report the effects of interventions studies according to
socioeconomic position, using widely acceptable measures, as a matter of
course.

1. Aldrich R, Kemp L, Williams JS, Harris E, Simpson S, Wilson A, et
al. Using socioeconomic evidence in clinical practice guidelines. BMJ
2003;327(7426):1283-5.

2. Tudor Hart J. The inverse care law. Lancet 1971(7696):405-12.

3. Reading R, Colver A, Openshaw S, Jarvis S. Do interventions that
improve immunisation uptake also reduce social inequalities in uptake? BMJ
1994;308(6937):1142-4.

4. Victora C, Vaughan J, Barros F, Silva A, Tomasi E. Explaining
trends in inequities: evidence from Brazilian child health studies. The
Lancet 2000;356(9235):1093-8.

Competing interests:
None declared