Gregory D. Stevens

Vulnerability and Unmet Health Care Needs: The Influence of Multiple Risk Factors

AbstractCONTEXT: Previous studies have demonstrated a strong association between minority race, low socioeconomic status (SES), and lack of potential access to care (e.g., no insurance coverage and no regular source of care) and poor receipt of health care services. Most studies have examined the independent effects of these risk factors for poor access, but more practical models are needed to account for the clustering of multiple risks. OBJECTIVE: To present a profile of risk factors for poor access based on income, insurance coverage, and having a regular source of care, and examine the association of the profiles with unmet health care needs due to cost. Relationships are examined by race/ethnicity. DESIGN: Analysis of 32,374 adults from the 2000 National Health Interview Survey. MAIN OUTCOME MEASURES: Reported unmet needs due to cost: missing/delaying needed medical care, and delaying obtaining prescriptions, mental health care, or dental care. RESULTS: Controlling for personal demographic and community factors, individuals who were low income, uninsured, and had no regular source of care were more likely to miss or delay needed health care services due to cost. After controlling for these risk factors, whites were more likely than other racial/ethnic groups to report unmet needs. When presented as a risk profile, a clear gradient existed in the likelihood of having an unmet need according to the number of risk factors, regardless of racial/ethnic group. CONCLUSION: Unmet health care needs due to cost increased with higher risk profiles for each racial and ethnic group. Without attention to these co-occurring risk factors for poor access, it is unlikely that substantial reductions in disparities will be made in assuring access to needed health care services among vulnerable populations.

Racial and Ethnic Disparities in the Primary Care Experiences of Children: A Review of the Literature

Substantial racial and ethnic disparities persist in children’s health and use of health services in the United States. Although equitable access to primary care services is widely promoted as one of the most feasible remedies to reduce health disparities, there has only recently been an effort to assess its quality, particularly for children. Racial and socioeconomic differences in access to care have been previously well documented, but recent research has begun to elucidate differences in more qualitative experiences in the receipt of primary care. This article presents a synthesis and critique of the existing research according to the core attributes of primary care: first-contact care, longitudinality, comprehensiveness, and coordination. Finally, the article proposes an agenda for further research into the pathways by which racial and ethnic disparities in primary care exist.

Disparities in access to care and satisfaction among U.S. children: the roles of race/ethnicity and poverty status.

Objectives. The study assessed the progress made toward reducing racial and ethnic disparities in access to health care among U.S. children between 1996 and 2000. Methods. Data are from the Household Component of the 1996 and 2000 Medical Expenditure Panel Survey. Bivariate associations of combinations of race/ethnicity and poverty status groups were examined with four measures of access to health care and a single measure of satisfaction. Logistic regression was used to examine the association of race/ethnicity with access, controlling for sociodemographic factors associated with access to care. To highlight the role of income, we present models with and without controlling for poverty status. Results. Racial and ethnic minority children experience significant deficits in accessing medical care compared with whites. Asians, Hispanics, and blacks were less likely than whites to have a usual source of care, health professional or doctor visit, and dental visit in the past year. Asians were more likely than whites to be dissatisfied with the quality of medical care in 2000 (but not 1996), while blacks and Hispanics were more likely than whites to be dissatisfied with the quality of medical care in 1996 (but not in 2000). Both before and after controlling for health insurance coverage, poverty status, health status, and several other factors associated with access to care, these disparities in access to care persisted between 1996 and 2000. Conclusions. Continued monitoring of racial and ethnic differences is necessary in light of the persistence of racial/ethnic and socioeconomic disparities in access to care. Given national goals to achieve equity in health care and eliminate racial/ethnic disparities in health, greater attention needs to be paid to the interplay of race/ethnicity factors and poverty status in influencing access.

Duration of a Well-Child Visit: Association With Content, Family-Centeredness, and Satisfaction

BACKGROUND: Studies of pediatric primary care suggest that time is an important limitation to the delivery of recommended preventive services. Given the increasingly frenetic pace of pediatric practice, there is an increased need to monitor the length of pediatric visits and the association of visit length with content, family-centered care, and parent satisfaction with care. OBJECTIVE: To examine the length of well-child visits and the associations of visit length with content, family-centered care, and parent satisfaction among a national sample of children. METHODS: We conducted a cross-sectional telephone survey of parents of children aged 4 to 35 months from the 2000 National Survey of Early Childhood Health (n = 2068). RESULTS: One-third (33.6%) of parents reported spending ≤10 minutes with the clinician at their last well-child visit, nearly half (47.1%) spent 11 to 20 minutes, and 20.3% spent >20 minutes. Longer visits were associated with more anticipatory guidance, more psychosocial risk assessment, and higher family-centered care ratings. A visit of >20 minutes was associated with 2.4 (confidence interval [CI]: 1.5–3.7) higher odds of receiving a developmental assessment, 3.2 (CI: 1.7–6.1) higher odds of recommending the clinician, and 9.7 (CI: 3.5–26.5) higher odds of having enough time to ask questions. CONCLUSIONS: Many well-child visits are of short duration, and shorter visits are associated with reductions in content and quality of care and parent satisfaction with care. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. The results of this study should be interpreted in light of changes in practice standards, reimbursement, and outcome measurement that have taken place since 2000 and the limitations of the measurement of utilization solely on the basis of parent report.

Gradients in the Health Status and Developmental Risks of Young Children: The Combined Influences of Multiple Social Risk Factors

Objectives: To analyze child vulnerability as a profile of multiple risk factors for poorer health based on race/ethnicity, social class (maternal education and family poverty status), child health insurance coverage, and maternal mental health. Profiles are examined in relation to disparities in the health status and developmental risks of young children. Data Sources: Cross-sectional data on 2,068 children ages 4–35 months from the 2000 National Survey of Early Childhood Health. Study Design: Multiple logistic regression models are used to examine risk profiles in relation to child health status and developmental risk (based on parent concerns about development). The profiles are also examined in relation to three measures of basic access to health care: telephone contact with a physician, well-child visit in the past year, and missed or delayed needed care. Principal Findings: About one-third of (or 3.1 million) young children in the United States have two or more risk factors (RF) for poor health. Controlling for other family factors, having more RFs is associated with poorer health status (i.e., percent reported “good/fair/poor” vs. “excellent/very good”) and being higher risk for developmental delays. For example, the likelihood of having either poorer health or higher developmental risk increases with each RF (vs. zero): 1 RF (OR = 1.70, CI: 1.20–2.38), 2 RFs (OR = 3.28, CI: 2.27–4.73), 3 RFs (OR = 4.69, CI: 2.84–7.73), 4 RFs (OR = 14.58, CI: 4.98–42.64). Higher RFs were also associated with poorer health care access. Conclusions: This study demonstrates a dose–response relationship of higher risk profiles with poorer child health status and higher developmental risk. Because children with higher profiles of risk are also more likely to lack access to care, this suggests that children who most need care have the greatest difficulty obtaining it. Addressing health gradients for vulnerable children will require explicit attention to these multiple, overlapping risk factors.

Prevalence and correlates of high-quality basic pediatric preventive care.

Background. The list of recommended pediatric preventive services has grown considerably in the past decade, and clinician variability, clinician distribution, and other correlates of provision of these basic preventive services (BPS) are not known. Objective. To describe the proportion of high-quality basic pediatric preventive services, exclusive of immunizations, reported by parents and to identify sociodemographic and health system predictors and health service correlates of provision of these services. Study Design. The study used cross-sectional data on 2041 children, 4 to 35 months of age, in the 2000 National Survey of Early Childhood Health. Outcome Measures. The BPS measure assesses the receipt of (1) developmental assessment, (2) injury prevention counseling, (3) screening for parental smoking, (4) guidance on reading to the child, and (5) guidance on 14 other topics (assessed as a composite score). The BPS scale categorizes the receipt of services as excellent, good, fair, or poor. Results. Most children received excellent (34.9%) or good (31.5%) care, but many received fair (24.9%) or poor (8.7%) care. Sociodemographic and health care factors such as race/ethnicity, insurance, and practice setting were not associated with BPS levels. Higher BPS scores were associated with parental reports of longer well-child visits, more counseling regarding family and community risk factors, lower rates of delayed or missed care, and greater satisfaction. Conclusions. Two thirds of children receive good or excellent basic preventive care, as determined with this composite, and no disparities according to race/ethnicity, income, or health insurance status of families (which are often found to be associated with health care access) were found. This equitable distribution of high-quality care suggests a high level of clinician professionalism. Duration of visits may be a key factor to improve quality of care. Because of its association with other services, processes, and outcomes of care, the BPS scale may serve as a useful construct for monitoring quality and stimulating efforts to improve national pediatric preventive care.

Parenting-related stressors and self-reported mental health of mothers with young children

OBJECTIVES We assessed whether there were associations between maternal mental health and individual and co-occurring parenting stressors related to social and financial factors and child health care access. METHODS We used cross-sectional data from the 2000 National Survey of Early Childhood Health. The 5-item Mental Health Inventory was used to measure self-reported mental health. RESULTS After we controlled for demographic covariates, we found that the following stressors increased the risk of poor maternal mental health: lack of emotional (odds ratio [OR] = 3.4; 95% confidence interval [CI] = 2.0, 5.9) or functional (OR=2.2; 95% CI=1.3, 3.7) social support for parenting, too much time spent with child (OR=3.5; 95% CI=2.0, 6.1), and difficulty paying for child care (OR=2.3; 95% CI=1.4, 3.9). In comparison with mothers without any parenting stressors, mothers reporting 1 stressor had 3 times the odds of poor mental health (OR = 3.1; 95% CI = 2.1, 4.8), and mothers reporting 2 or more stressors had nearly 12 times the odds (OR = 11.7; 95% CI = 7.1, 19.3). CONCLUSIONS If parenting stressors such as those examined here are to be addressed, changes may be required in community support systems, and improvements in relevant social policies may be needed.

Enrolling Vulnerable, Uninsured but Eligible Children in Public Health Insurance: Association With Health Status and Primary Care Access

OBJECTIVES. Given that more than two thirds of uninsured children in California are eligible for public health insurance coverage, this study examined differences in primary care access and health status between uninsured but eligible (UBE) children and those who were insured. METHODS. Using data on 19485 children from the 2001 California Health Interview Survey, this study examined differences in primary care access and health status for UBE children versus those who were enrolled in public coverage. Results are stratified by profiles of other risk factors (RF) for poor access: nonwhite, low income, low parent education, and non–English speaking. RESULTS. UBE children were less likely than publicly enrolled children to have a physician visit in the past year, dental visit in the past year, and a regular source of care. On the basis of differences between the UBE children and enrollees in the prevalence of each dependent measure, UBE children with multiple RFs experienced greater disparities than UBE children with fewer RFs. For example, enrollees were more likely than UBE children to have a regular source of care among children with 2, 3, or 4 RFs (differences of 26, 26, and 25 percentage points, respectively) compared with 1 RF (19 percentage points) and 0 RFs (12 percentage points). A similar pattern was found for dental visits but not physician visits. Although there was no difference in health status between UBE children and enrollees overall, enrollees were more likely than UBE children to have excellent/very good health status among children with 2 RFs (difference of 9 percentage points), 3 RFs (12 percentage points), and 4 RFs (11 percentage points). CONCLUSIONS. This study demonstrates that UBE children in California have poorer access to care compared with enrollees, and those with the highest levels of risk have poorer health status. This suggests that providing insurance to these children (and particularly those with multiple RFs) may lead to improved access and health for these vulnerable children.

The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured.

Community health centers (CHCs) have long served an important safety-net healthcare delivery role for vulnerable populations. Federal efforts to expand CHCs, while potentially reducing the Federal budget for Medicaid, raise concern about how Medicaid and uninsured patients of CHCs will continue to fare. To examine the primary care experiences of uninsured and Medicaid CHC patients and compare their experiences with those of similar patients nationally, cross-sectional analyses of the 2002 CHC User Survey with comparison data from the 1998 and 2002 National Health Interview surveys were done. Self-reported measures of primary care access, longitudinality, and comprehensiveness of care among adults aged 18 to 64 years were used. Despite poorer health, CHCs were positively associated with better primary care experiences in comparison with similar patients nationally. Uninsured CHC patients were more likely than similar patients nationally to report a generalist physician visit in the past year (82% vs 68%, P < .001), having a regular source of care (96% vs 60%, P < .001), receiving a mammogram in the past 2 years (69% vs 49%, P < .001), and receiving counseling on exercise (68% vs 48%, P < .001). Similar results were found for CHC Medicaid patients versus Medicaid patients nationally. Even within CHCs, however, Medicaid patients tended to report better primary care experiences than the uninsured. Health centers appear to fill an important gap in primary care for Medicaid and uninsured patients. Nonetheless, this study suggests that Medicaid insurance remains fundamental to accessing high-quality primary care, even within CHCs.

Patient-Provider Racial and Ethnic Concordance and Parent Reports of the Primary Care Experiences of Children

PURPOSE Studies among adults suggest that patient-provider racial concordance is associated with higher satisfaction and partnership with physicians. It remains unknown whether similar findings are true for children. This study examines the association of race/ethnicity concordance with parent reports of children’s primary care experiences. METHODS We completed telephone interviews with a random, cross-sectional sample of 413 parents of elementary school children, aged 5 to 12 years, enrolled in a single large school district serving 3 cities in San Bernardino, Calif. Parents reported on their children’s primary care experiences, and the responses were compared between children in race concordant and discordant patient-provider relationships. RESULTS We assessed parent reports of 6 structure and process features of primary care: first-contact care (accessibility, utilization), longitudinality (strength of affiliation, interpersonal relationship), and comprehensiveness (services offered, received). Before and after controlling for demographics, socioeconomic status, and health system factors, race/ethnicity concordance was not associated with children’s primary care experiences. Minority parents generally reported poorer experiences than whites in several domains of primary care, but the only significant effect of race/ethnicity concordance was slightly better primary care utilization for whites in concordant relationships, which did not hold after adjustment. CONCLUSION In contrast with studies among adults, patient-provider race/ethnicity concordance was not associated with parent reports of primary care experiences in our sample of children. It is possible that provider biases or patient expectations that contribute to disparities in care for adults are attenuated in relationships involving children.