Modifiable Determinants of Healthcare Utilization: DISCUSSION
These data suggest that within each age-gender subgroup, whether or not an individual has health insurance and a source of usual care is the most important modifiable factors driving use of needed health services within the African-American population. Poverty is also a significant and modifiable factor. Combining the three factors of health insurance, adequate income, and having a primary care medical home was a powerful predictor of the use of specific health services that could improve health outcomes within the African-American population. For example, use of doctor’s office visits was four times higher among African-American patients who were “health-advantaged” (i.e., individuals with all three factors present—insured, nonpoor persons with a defined medical home) compared with the “health disadvantaged”.
These disparities in healthcare utilization are important, because ultimately they drive specific racial disparities in health status and health outcomes. For example, African-American patients are significantly less likely than whites to receive influenza vaccine, more likely to report barriers to obtaining mammography, more likely to be diagnosed with late-stage cancer, and more likely to die from cancer. Regardless of race or ethnicity, women participating in routine mammography screening had earlier-stage disease by five-to-13 percentage points.” kamagra jelly uk
In previous studies, the modifiable risk factors of having health insurance and having a usual source of care strongly and independently predicted use of essential preventive services. Selvin et al. found that having a medical home was “the most important predictor” of cancer screening use for all racial-ethnic groups.” In one study, in which each patient had not only a usual source of care but also an ongoing relationship with his/her own family physician, there were no racial differences in the provision of screening services, and African Americans were actually slightly more likely than whites to receive preventive counseling with regard to health behaviors! Unfor tunately, the usual source of care for African-American individuals is less likely to be in settings that offer continuity of care with a personal physician and more likely to be in hospital outpatient departments orEDs.”
To some extent, the issues may also be quite different for each minority group. For example, in analyzing data from nationally representative surveys conducted in 1996-1997 and 1998-1999, Hargraves found that more than 80% of the difference between Hispanic and white, non-Hispanic respondents was due to differences in measured characteristics (e.g., insurance coverage, income, and available safety net services), but that these factors did not sufficiently explain the black-white differences. For the Hispanic population, primary language (Spanish-speaking vs. English-speaking) is also a significant predictor of use of physician visits, flu vaccination, or mental health services. Viagra Online Canadian Pharmacy
Race, poverty, and having health insurance and/or a usual source of care have also been correlated with hospitalization for ambulatory care sensitive conditions. National Hospital Ambulatory Medical Care Survey (NHAMCS) data also showed that follow-up arrangements for African-American patients were less likely to result in ongoing primary care.” Previous studies have also shown significant racial-ethnic differences in the use of medication related to specific high-disparity conditions, such as hypertension, asthma, diabetes, depression, schizophrenia, hyperlipi-demia, and HIV/AIDS. Inadequate treatment of any one or more of these conditions has the potential to drive disparate rates of disability and death in the African-American population. In our study, use of prescription drugs was significantly lower among the uninsured and lowest among the health-disadvan-taged. This could reflect either lower rates of care for acute and chronic conditions (fewer initial prescriptions) or lower prescription refill rates, or both.
The only healthcare utilization rates that did not show a significant difference between the insured and uninsured or even between the most-advantaged and most-disadvantaged African Americans was the use of the ED, the one form of access to care that is mandated by federal law. The Emergency Medical Treatment and Active Labor Act (EMTALA) makes medical emergency visits (including obstetrical patients in active labor) the only form of healthcare in America in which patients must be at least seen, evaluated, and stabilized regardless of insurance or ability to pay. By this legislation, the ED becomes the de facto safety net for low-income, uninsured patients with no primary care medical home. The fact that there were no differences in ED visit rates between advantaged and disadvantaged African-American persons is an interesting “within-group” finding in itself, because one would expect the disadvantaged group to have a greater burden of disease and healthcare needs, and therefore a higher emergency visit rate. In fact, previous NHAMCS studies have found significant black-white differences in ED utilization rates (71% higher for African-American than for white persons). While the visit rate for elderly African Americans increased by 59% in just seven years (from 1992 to 1997), the visit rate for elderly whites did not change.
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However, in spite of an equal rate of reported ED visits in our study between advantaged and disadvantaged African Americans, the ratio of hospital admissions to ED visits was dramatically lower for low-income, uninsured individuals with no usual source of care (one admission for every 10 ED visits) than for insured, upper-income, individuals with a medical home (one admission for every two ED visits). A cross-sectional study of 29,237 admissions to 100 U.S. hospitals in 1993 and 1994 found that uninsured patients were sicker than the insured but had shorter lengths of stay and poorer health outcomes, suggesting that the uninsured might not be receiving necessary care. The ED visit to hospital admission ratios in our data cannot be explained by suggesting that disadvantaged African-American patients are using the ED inappropriately or for nonurgent conditions, because the disadvantaged are visiting the ED at precisely the same rate as are the advantaged patients.
One source of variation might be the hospitals visited by disadvantaged patients. Analysis of 1999 data from the NHAMCS suggested significant variation among hospital EDs in the percent of patients admitted to the hospital.” Another possibility is that advantaged (especially insured) patients are being admitted to the hospital with a lower threshold of clinical severity than are the disadvantaged, because there are significant financial incentives for hospitals not to admit uninsured, low-income patients. Hospitals may seek alternatives to hospital admission (prolonged ED observation, or stabilization and discharge) especially for the uninsured, in order to avoid absorbing the cost of an indigent hospitalization.
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One potential weakness of our study is the relatively small proportion of individuals within the African-American population who meet all three criteria for being health-disadvantaged. This is an important point in itself, which is that many articles present the African-American population as being almost exclusively disadvantaged. Confounding a person’s race with potentially changeable risk factors (i.e., listing “poor, black, and uninsured” in the same breath) is not only counterproductive but also inaccurate. However, multivariate analysis suggests that each of our three “disadvantaged” criteria contribute independently to the variation in use of healthcare services within the African-American population. While poverty is a fundamental root cause, these data also suggest that significant reductions in disparities might be achieved with focused interventions to achieve universal health insurance coverage and universal access to a primary care medical home.
CONCLUSIONS
The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients. Targeted interventions, such as provision of health insurance, poverty reduction, and eliminating barriers to having a primary care medical home, could reduce or eliminate disparities in use of preventive and primary care services (and other needed healthcare) for the African-American population. suhagra 100
