Modifiable Determinants of Healthcare Utilization
INTRODUCTION
Racial and ethnic disparities in healthcare have been documented in numerous studies, which have been summarized in national reports, such as the Institute of Medicine’s Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care* and various Kaiser Family Foundation reports on Race, Ethnicity, and Medical Care. Some of the most rigorously documented studies have shown racial differences in the use of cardiovascular procedures for patients hospitalized with coronary heart disease, but clinical and demographic factors still do not adequately explain why African Americans are significantly less likely to undergo revascularization procedures.”
Studies exploring disparities in cardiac procedures have traditionally been framed as studies of black-white differences, including racism as a cause of such disparities. Far fewer studies have sought to assess the modifiable factors that drive disparities within the subgroup of African Americans. In other words, why do some African-American patients receive optimal care, while many others do not? Understanding “within-group” differences may better identify specific factors around which interventions could be designed to reduce health disparities in the African-American population. The Anderson and Aday model provides a conceptual framework for analyzing modifiable determinants of healthcare utilization, and this framework can be further informed by Williams’ sociologic perspective on personal and contextual factors that uniquely influence health status among African Americans.
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Access to care through health insurance, especially Medicare, has been shown to have a significant impact on improving access to care and health outcomes in high disparity groups, such as the African-American population. Zuvekas et al. concluded from their own analyses of MEPS data that while health insurance did not by itself explain the persistent racial & ethnic disparities, it was a significant contributing factor. However, the disparities literature has tended to lump modifiable risk factors with nonmodifiable demographic characteristics of the individual in explaining variations in the use of health services. For example, studies identify being “poor, black, and uninsured” as common risk factors for lower overall healthcare utilization and costs, without differentiating the impact of modifiable risk factors (uninsurance, medical home, etc.) on members of each racial-ethnic subgroup. In this study, therefore, we have sought to understand the modifiable determinants of healthcare utilization within the African-American population in order to focus on intervention points that could imp rove health outcomes for this high-disparity population. We also assessed the impact of clustered factors among the healthcare disadvantaged (poor, uninsured, with no medical home) vs. the healthcare advantaged (non-poor, insured, with a medical home).
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