Modifiable Determinants of Healthcare Utilization: METHODS Data
Source
Data for the U.S. civilian, noninstitutionalized population were taken from the 1999 Medical Expenditure Panel Survey (MEPS) sponsored by the Agency for Healthcare Research and Quality (AHRQ). MEPS is a nationally representative survey of a sample of households drawn from previous National Health Interview Survey (NHIS) participants. Data in 1999 were collected for 23,565 persons by computer-assisted personal interviews.
In this study, household component records describing the sociodemographics, health insurance coverage, and healthcare utilization of survey participants were analyzed. MEPS records are weighted for the calculation of national estimates, usually with relatively small standard errors. Race is recorded as one of five categories in the MEPS records. African Americans were substantially oversampled in the 1999 survey. We analyzed data from all 3,462 all-civilian, noninstitutionalized African-American respondents to the survey, representing a U.S. African-American population of 36,538,639. cheap cialis canadian pharmacy
Table 1. Mean Annual Healthcare Utilization for African Americans by Demographic Characteristics and Modifiable Factors (Insurance Status and Usual Source of Care), 1999
| Category/ |
Number |
Percent |
Office |
Hosp Outpt. |
ED |
Hospital |
Hospital |
Rx Fills |
| Item |
Visits |
Clinic Visits |
Visits |
Discharges Bed-Days |
+ Refills |
|||
| Age Group | ||||||||
| Under 18 |
11,937,112 |
33.1 |
1.58 |
0.08 |
0.15 |
0.03 |
0.10 |
1.38 |
| 18-44 |
14,773,451 |
40.9 |
2.19 |
0.31 |
0.19 |
0.09 |
0.28 |
3.32 |
| 45-64 |
6,522,838 |
18.1 |
3.82 |
0.59 |
0.20 |
0.12 |
0.72 |
12.07 |
| 65+ |
2,872,592 |
8.0 |
6.77 |
1.07 |
0.22 |
0.23 |
1.30 |
21.81 |
| P value** |
<0.01 |
<0.01 |
0.18 |
O.01 |
<0.01 |
O.01 |
||
| Sex | ||||||||
| Male |
16,987,105 |
46.5 |
2.24 |
0.27 |
0.16 |
0.06 |
0.40 |
4.41 |
| Female |
19,551,534 |
53.5 |
2.96 |
0.41 |
0.20 |
0.12 |
0.48 |
6.81 |
| P value** |
<0.01 |
0.13 |
0.03 |
<0.01 |
0.43 |
<0.01 |
||
| MSA vs. non-MSA (Urban-rural) | ||||||||
| MSA |
31,833,017 |
88.2 |
2.60 |
0.35 |
0.17 |
0.08 |
0.31 |
5.41 |
| Non-MSA |
4,272,976 |
11.8 |
2.96 |
0.31 |
0.25 |
0.15 |
0.93 |
8.13 |
| P value** |
0.25 |
0.78 |
0.02 |
O.01 |
0.01 |
0.01 |
||
| Family income as % fed. poverty level | ||||||||
| Poor |
8,799,737 |
24.1 |
2.78 |
0.43 |
0.24 |
0.13 |
0.67 |
7.19 |
| Near poor |
2,328,651 |
6.4 |
1.78 |
0.22 |
0.17 |
0.08 |
0.42 |
5.40 |
| Low Income |
6,393,948 |
17.5 |
2.37 |
0.34 |
0.19 |
0.08 |
0.38 |
5.02 |
| Middle Income 10,643,391 | 29.1 |
2.88 |
0.24 |
0.17 |
0.09 |
0.50 |
5.57 |
|
| High Income |
8,372,911 |
22.9 |
2.60 |
0.42 |
0.13 |
0.06 |
0.20 |
4.87 |
| P value** |
0.02 |
0.28 |
0.03 |
0.09 |
<0.01 |
0.10 |
||
| Health Insurance Coverage | ||||||||
| Any private |
21,240,269 |
58.1 |
2.61 |
0.33 |
0.15 |
0.07 |
0.31 |
4.93 |
| Public only |
9,999,210 |
27.4 |
3.44 |
0.51 |
0.27 |
0.16 |
0.88 |
9.37 |
| Uninsured |
5,299,199 |
14.5 |
1.16 |
0.08 |
0.15 |
0.04 |
0.17 |
1.83 |
| P value** |
O.01 |
O.01 |
O.01 |
O.01 |
O.01 |
O.01 |
||
| Has Usual Source of Care? | ||||||||
| Yes |
28,389,137 |
20.0 |
3.08 |
0.41 |
0.19 |
0.10 |
0.44 |
6.89 |
| No |
7,089,761 |
80.0 |
1.08 |
0.13 |
0.15 |
0.04 |
0.13 |
1.55 |
| P value** |
<0.01 |
<0.01 |
0.14 |
<0.01 |
O.01 |
<0.01 |
||
| Total African-American Population in MEPS* | ||||||||
|
36,538,639 |
100.0 |
2.63 |
0.34 |
0.18 |
0.09 |
0.45 |
5.69 |
|
| * This represents the number of individuals in the U.S. African-American population, a number generated | ||||||||
| by applying statistical weights to raw survey data. Due to missing data on some items, totals for some | ||||||||
| categories may be less than 36,538,639; ** derived from ANOVA F values | ||||||||
Study Variables
Dependent variables related to our research question consisted of measures of utilization in the various healthcare settings and for medications, including the following five variables:
1) Visits to physician’s office (or other health professional provider’s office).
2) Visits to hospital outpatient departments (hospital-based clinics).
3) Inpatient hospitalizations—discharges and nights in hospital.
4) Visits to emergency departments (EDs).
5) Prescribed medications—fills.
Self-reported health status and self-reported mental health status (two variables) were also assessed as dependent variables but are not measures of healthcare utilization. erectalis
Table 2. Adjusted Odds Ratios for Predictors of Healthcare Utilization (yes/no for each item) among African Americans, 1999 (with 95% Confidence Intervals)
| Category/Item | Office Visits Hosp Outpt. Clinic Visits ED Visits Hospital Discharges Rx Fills + Refills | ||||
| Age Group Under 18 18-44 45-64 65+ | 0.20 (0.13, 0.30) 0.23 (0.16, 0.35) 0.47 (0.31,0.71) 1.00 | 0.16 (0.10, 0.24) 0.49 (0.32, 0.73) 0.86 (0.56, 1.30) 1.00 | 0.81 (0.55, 1.18) 1.19 (0.81, 1.76) 1.15 (0.73, 1.80) 1.00 | 0.81 (0.09, 0.30) 0.80 (0.47, 1.38) 0.96 (0.54, 1.72) 1.00 | 0.09 (0.06, 0.14) 0.17 (0.11,0.27) 0.35 (0.22, 0.54) 1.00 |
| Sex Male
Female |
0.65 (0.54, 0.77) 1.00 | 0.76 (0.60, 0.96) 1.00 | 0.91 (0.73, 1.14) 1.00 | 0.50 (0.36, 0.70) 1.00 | 0.70 (0.59, 0.83) 1.00 |
| MSA vs. non-MSA
MSA 0.92 (0.67, 1.26) Non-MSA 1.00 |
0.91 (0.59, 1.42) 1.00 | 0.78 (0,55, 1.09) 1.00 | 0.63 (0.45, 0.87) 1.00 | 0.79 (0.61, 1.03) 1.00 | |
| Income/Poverty Status
Poor 0.82 (0.5 b 1.34) Near Poor 0.50 (0.27, 0.93) Low Income 0.76 (0.53, 1.11) Middle Income 0.83 (0.57, 1.21) High Income 1.00 |
1.39 (0.80, 2.41) 0.76 (0.39, 1.47) 0.92 (0.56, 1.52) 1.00 (0.66, 1.51) 1.00 | 1.63 (1.02, 2.61) 1.10(0.58, 2.08) 1.39 (0.85, 2.28) 1.42 (0.97, 2.08) 1.00 | 1.38 (0.75, 2.54) 0.98 (0.50, 1.94) 1.09 (0.61, 1.96) 1.40 (0.86, 2.26) 1.00 | 0.93 (0.62, 1.38) 0.68 (0.41, 1.12) 0.90 (0.67, 1.22) 0.76 (0.55, 1.05) 1.00 | |
| Health Insurance
Any Private 3.64 (2.79, 4.75) Public Only 4.13(2.80,6.09) Uninsured 1.00 |
1.82 (1.08, 3.09) 2.07 (1.27, 3.36) 1.00 | 1.28 (0.82, 1.99) 1.99 (1.23, 3.23) 1.00 | 1.36 (0.72, 2.58) 3.06 (1.61,5.81) 1.00 | 2.57 (1.97, 3.35) 2.96 (2.09, 4.20) 1.00 | |
| Usual source of care?
Yes 4.47 (3.37, 5.92) No 1.00 |
3.99 (2.02, 7.87) 1.00 | 1.00(0.69, 1.44) 1.00 | 1.91 (1.12,3.27) 1.00 | 2.73 (2.01,3.70) 1.00 | |
Predictor variables used in the analysis were:
1) Age—four groups; children (under 18 years of age), adults 18-44,45-64, and the elderly (over 64 years of age).
2) Sex—female or male.
3) Residence—resident of a Metropolitan Statistical Area (MSA) county or a resident of a non-MSA county. Small samples of African Americans in some regions precluded using census region in the model.
4) Household income—reported family income divided by the federal poverty level based on family size and composition, with the resulting percentages grouped into five categories (<100% of federal poverty level, 100-124% of federal poverty level, 125-199% of federal poverty level, 200-399% of federal poverty level, and >400% of federal poverty level).
5) Health insurance—three groups: private insurance; public insurance only (Medicare, Medicaid and dual-eligibles); and no insurance, without regard for adequacy of coverage.
6) Usual source of care—response to the question: “Is there a particular doctor’s office, clinic, health center, or other place that you go if you are sick or need advice about your health?
online pharmacy no prescription needed
Analytical Strategy
Descriptive analyses were first performed estimating services received in each care setting and utilization of prescribed medicines. Comparisons on these measures were made across categories of the predictor variables enumerated above for African Americans (Table 1). We then evaluated potential predictor variables for inclusion in multivariate analyses. Bivariate tests indicated strong associations between each of the predictor variables and measures of healthcare utilization in at least one setting. We also tested the associations with and with out children and the elderly in the analysis, and found similar patterns. Therefore, all of the listed variables were used in separate logistic and linear regressions to model healthcare use by the setting in which the service was received. Logistic regression was performed to model whether or not an individual had received care at least once for each of the settings and for receipt of at least one prescribed medication fill. Adjusted odds ratios for whether or not a service was received were calculated for each predictor variable (Table 2), because of the potential for skewing of data by the large numbers of persons who had zero events (zero hospital admissions or emergency visits, for example). Linear regression was done to model the actual quantity of services and medication fills received. Its beta coefficients are straightforward measures of the strength of the effect of predictor variables on healthcare utilization (Table 3). Analyses were done with SUDAAN to adjust variance estimates due to MEPS survey design complexity, particularly the substantial over-sampling of certain population groups.
Table 3. Multivariate Analysis—Regression Coefficients and P Values for Predictors of Healthcare Utilization among African Americans, 1999
| Category/Item Office Visits | Hosp Outpt. Clinic Visits | ED Visits Hospital Discharges | Rx Fills + Refills | ||||||
| Beta |
p-value |
Beta |
p-value |
Beta p-value | Beta |
p-value |
Beta p-value | ||
| Overall Model |
<0.01 |
<0.01 |
<0.01 |
<0.01 |
<0.01 | ||||
| Age Group |
<0.01 |
<0.01 |
0.03 |
<0.01 |
<0.01 | ||||
| Under 18 -4.93 |
<0.01 |
-0.96 |
<0.01 |
-0.03 |
0.35 |
-1.13 |
<0.01 |
-19.63 |
<0.01 |
| 18-44 -3.74 |
<0.01 |
-0.60 |
0.04 |
0.04 |
0.35 |
-0.71 |
0.04 |
-15.65 |
<0.01 |
| 45-64 -2.41 |
O.01 |
-0.37 |
0.22 |
0.05 |
0.32 |
-0.30 |
0.41 |
-7.47 |
O.01 |
| 65+ 0.00 | 0.00 | 0.00 | 0.00 |
0.00 |
|||||
| (Reference Group) | |||||||||
| Sex |
0.25 |
0.51 |
0.14 |
0.48 |
0.04 | ||||
| Male -0.30 |
0.25 |
-0.06 |
0.51 |
-0.03 |
0.14 |
0.09 |
0.48 |
-0.88 |
0.04 |
| Female 0.00 | 0.00 | 0.00 | 0.00 |
0.00 |
|||||
| (Reference Group) | |||||||||
| MSA vs. non-MSA |
0.47 |
0.56 |
0.05 |
0.01 |
0.03 | ||||
| MSA -0.20 |
0.47 |
0.07 |
0.56 |
-0.07 |
0.05 |
-0.56 |
0.01 |
-1.91 |
0.03 |
| Non-MSA 0.00 | 0.00 | 0.00 | 0.00 |
0.00 |
|||||
| (Reference Group) | |||||||||
| Income/Poverty |
0.02 |
0.37 |
0.28 |
<0.01 |
0.01 | ||||
| Poor 0.36 |
0.40 |
0.08 |
0.78 |
0.07 |
0.08 |
0.35 |
0.03 |
2.88 |
O.01 |
| Near Poor -0.36 |
0.09 |
-0.14 |
0.52 |
0.02 |
0.72 |
0.23 |
0.20 |
0.82 |
0.40 |
| Low Income 0.03 |
0.92 |
0.00 |
0.99 |
0.05 |
0.21 |
0.16 |
0.12 |
0.97 |
0.12 |
| Middle Income 0.44 |
0.25 |
-0.14 |
0.23 |
0.04 |
0.12 |
0.31 |
O.01 |
1.18 |
0.02 |
| High Income 0.00 | 0.00 | 0.00 | 0.00 |
0.00 |
|||||
| (Reference Group) | |||||||||
| Health Insurance |
0.01 |
<0.01 |
<0.01 |
0.01 |
<0.01 | ||||
| Any Private 1.03 |
0.02 |
0.23 |
0.07 |
0.02 |
0.71 |
0.18 |
0.04 |
2.32 |
<0.01 |
| Public Only 1.56 |
O.01 |
0.35 |
0.02 |
0.13 |
O.01 |
0.51 |
O.01 |
4.79 |
<0.01 |
| Uninsured 0.00 | 0.00 | 0.00 | 0.00 |
0.00 |
|||||
| (Reference Group) | |||||||||
| Usual source of care? |
<0.01 |
<0.01 |
0.31 |
<0.01 |
<0.01 | ||||
| Yes 1.69 |
<0.01 |
0.24 |
0.41 |
0.03 |
0.31 |
0.28 |
<0.01 |
4.11 |
O.01 |
| No 0.00 | 0.00 | 0.00 | 0.00 |
0.00 |
|||||
| (Reference Group) | |||||||||
Finally, we also assessed the clustered effect of certain predictor variables, identifying individuals at the extremes of being advantaged or disadvantaged with regard to healthcare (Table 4). Members of the healthcare-disadvantaged group have family income below the poverty level, no health insurance, and no usual source of care. The healthcare advantaged group has family income above 400% of poverty, health insurance, and a usual source of care. buy kamagra
Table 4. Healthcare Utilization in 1999 for Healthcare-Disadvantaged* African Americans vs. Healthcare-Advantaged** African Americans
|
Mean |
SE Mean | P Value | |
| Office-Based Provider Visits
Disadvantaged* Advantaged** |
0.37 3.12 | 0.17 0.27 |
<.001 |
| Outpatient Debt Provider Visits
Disadvantaged Advantaged |
0.00 0.46 | 0.00 0.15 |
=0.002 |
| Emergency Room Visits
Disadvantaged Advantaged |
0.10 0.13 | 0.04 0.02 |
=0.496 |
| Hospital Discharges
Disadvantaged Advantaged |
0.01 0.07 | 0.01 0.01 |
=0.010 |
| Nights in Hospital
Disadvantaged Advantaged |
0.07 0.17 | 0.07 0.04 |
=0.214 |
| Home Health Provider Days
Disadvantaged Advantaged |
0.00 1.12 | 0.00 0.84 |
=0.182 |
| Prescription Meds Including Refills
Disadvantaged Advantaged |
0.93 6.05 | 0.70 0.50 |
O.001 |
| * Family income below poverty level no health insurance, no usual source of care. ** Family income above 400% poverty level, health insurance, a usual source of care. | |||
