Lydie A. Lebrun

Cancer Screening among Racial/Ethnic and Insurance Groups in the United States: A Comparison of Disparities in 2000 and 2008

Using the National Health Interview Survey, we examined associations among race/ ethnicity, insurance coverage, and cancer screening, and assessed changes in the magnitude of disparities over the past decade. Outcomes included recent cervical, breast, and colorectal cancer screening. Rates of colorectal screening increased for all racial/ethnic groups and some insurance groups from 2000 to 2008. However, rates of Pap tests and mammograms remained stagnant, and even decreased for certain groups. Some Hispanic-White and Asian-White disparities in cancer screening were reduced or eliminated over this time period. However, in 2008 Asians continued to have lower odds of Pap tests and Hispanics lower odds of colorectal cancer screening, even after accounting for potential confounders. There were no significant changes in Black-White disparities. The uninsured continued to be at a disadvantage for all three types of cancer screening, relative to the privately insured, as were publicly insured individuals with respect to colorectal cancer screening.

The influence of English proficiency on access to care

Objective. The number of individuals with limited English proficiency in the USA is large and rapidly growing. Consequently, addressing language barriers in access to medical care is becoming increasingly important. Previous studies have reported that individuals with limited English proficiency have more difficulty gaining access to care, compared to English-proficient individuals. We assessed the impact of English language proficiency on access to medical care, accounting for health and socioeconomic status, using nationally representative data. Design. Cross-sectional data from the 2006 National Health Interview Survey (n=29,868). The main outcome measures of interest were self-reported delayed medical care, forgone needed care, and visits to a health care professional. Results. In unadjusted analyses, individuals with limited English proficiency were more likely to forgo needed medical care and less likely to have a health care visit, compared to individuals who were proficient in English. There was no significant association between language proficiency and reports of delayed care. After accounting for individuals’ health and socioeconomic status, only the relationship between limited English proficiency and health care visits remained statistically significant. Most associations between language proficiency and access to care did not differ across various racial/ethnic groups. Conclusion. Results indicate that the choice of access measure may influence conclusions about language barriers in health care. Given the growing proportion of US residents with limited English proficiency, health care settings need to better address potential language barriers.

Health, Behavior, and Health Care Disparities: Disentangling the Effects of Income and Race in the United States

The literature on health disparities in the United States typically focuses on race/ethnicity or on socioeconomic status (SES) separately, but not often together. The purpose of the study was to assess the separate effects of race/ethnicity and SES on health status, health behaviors, and health care utilization. Cross-sectional analyses were conducted using the 2008 National Health Interview Survey (n = 17,337 non-elderly adults). SES disparities within specific racial groups were examined, as were race disparities within high and low SES groups. Within each racial/ethnic group, a greater proportion of low versus high SES individuals were in poor health, a lower proportion had healthy behaviors, and a lower proportion had access to care. In both SES groups, blacks and Hispanics had poorer health outcomes than whites. While whites were more likely to exercise than blacks and Hispanics, they are more likely to be smokers and less likely to have no or moderate alcohol consumption. Blacks had similar or better health care use than whites, especially for cancer screening; Hispanics had lower use within each SES group. Race/ethnicity disparities among adults of similar incomes, while important, were dwarfed by the disparities identified between high- and low-income populations within each racial/ethnic group.

Access to medical care, dental care, and prescription drugs: the roles of race/ethnicity, health insurance, and income.

Background: After accounting for socioeconomic factors and other demographic characteristics, racial/ethnic disparities in access to care were examined. Methods: Using nationally representative data on 34,403 individuals from the 2004 Medical Expenditure Panel Survey (MEPS), multiple logistic regression analyses for five outcome measures were conducted: self-reports of being unable to get medical care, dental care, or prescriptions in the past year; and having no doctor or dentist visits in the past year. The main independent variables were race/ethnicity, income, and insurance status. Results: Blacks and Hispanics were less likely to report difficulties in accessing medical care, dental care, and prescriptions as compared to whites. These disparities occurred primarily among the uninsured and Medicaid insured. More objective measures of utilization (ie, no doctor visit or dental visit during the past year) showed that minorities experienced less access than whites. Conclusions: Racial/ethnic disparities in access to care persist, and cannot be entirely explained by socioeconomic differences. In addition, the nature of these disparities depends on the socioeconomic position of racial/ethnic groups as well as the access measure used.

Development of the Chinese primary care assessment tool: data quality and measurement properties

OBJECTIVE The aim of this study was to translate and adapt the Primary Care Assessment Tool to assess the perceptions of the quality of primary care among patients in China and to examine the psychometric properties of the adapted Primary Care Assessment Tool Chinese version (PCAT-C). DESIGN A cross-sectional survey to assess the validity and reliability of PCAT-C using standard psychometric techniques. SETTING Outpatient departments of five state-level and provincial-level hospitals and four municipal-level hospitals as well as nine community health centers in Changsha, China. PARTICIPANTS A total of 2532 patients visiting primary care providers. RESULTS The PCAT-C was acceptable to patients, as evidenced by low proportions of missing data and a full range of possible scores for all items. Two items were eliminated following principal component analysis and reliability testing. The principal component analysis extracted eight multiple-item scales and one single-item scale. Multiple-item scales had reasonable internal consistency and high item-scale correlations. CONCLUSIONS This study represents the first attempt to construct an instrument for assessing patient reports on the quality of primary care, which is applicable to the Chinese context. Psychometric assessments indicated that the PCAT-C is a useful instrument for assessing the core attributes of primary care in China.

Access to Primary and Preventive Care among Foreign-Born Adults in Canada and the United States

OBJECTIVE To conduct cross-country comparisons and assess the effect of foreign birth on access to primary and preventive care in Canada and the United States. DATA SOURCES Secondary data from the 2002 to 2003 Joint Canada-United States Survey of Health. STUDY DESIGN Descriptive and comparative analyses were conducted, and logistic regression models were used to assess the effect of immigrant status and country of residence on access to care. Outcomes included measures of health care systems and processes, utilization, and patient perceptions. PRINCIPAL FINDINGS In adjusted analyses, immigrants in Canada fared worse than nonimmigrants regarding having timely Pap tests; in the United States, immigrants fared worse for having a regular doctor and an annual consultation with a health professional. Immigrants in Canada had better access to care than immigrants in the United States; most of these differences were explained by differences in socioeconomic status and insurance coverage across the two countries. However, U.S. immigrants were more likely to have timely Pap tests than Canadian immigrants, even after adjusting for potential confounders. CONCLUSIONS In both countries, foreign-born populations had worse access to care than their native-born counterparts for some indicators but not others. However, few differences in access to care were found when direct cross-country comparisons were made between immigrants in Canada versus the United States, after accounting for sociodemographic differences.

Racial/ethnic and socioeconomic disparities in access to care and quality of care for US health center patients compared with non-health center patients.

This study aims to compare racial/ethnic and socioeconomic disparities in access to care and quality of care for US health center patients and non–health center patients. Data for the study came from the 2002 Community Health Center User Survey and the 2003 National Healthcare Disparities Report. Descriptive analysis was performed using nationally representative survey data pertaining to access to care and quality of care for people of different races, ethnicities, incomes, and education levels. Results of the study show that health center patients experience fewer racial/ethnic and socioeconomic disparities in access to care and quality of care, compared with non–health center patients nationally. Racial/ethnic disparities favoring whites occur in non–health center patients in every measure of quality and access included in this study. Conversely, there are few disparities favoring whites among health center users. Education and income-related disparities occur for several measures of access and quality in both health center and non–health center patients; however, the magnitude of these disparities is usually greater among non–health center patients compared with health center patients. In conclusion, health centers have been touted for cost-efficient, high-quality care. This study adds to growing evidence that health centers may also help eliminate racial/ethnic and socioeconomic disparities in access to care and quality of care.

Physician Specialty and the Quality of Medical Care Experiences in the Context of the Taiwan National Health Insurance System

Objectives: Based on a recent patient survey from Taiwan, where there is universal health insurance coverage and unrestricted physician choice, this study examined the relationship between physician specialty and the quality of primary medical care experiences. Methods: We assessed ambulatory patients’ experiences with medical care using the Primary Care Assessment Tool, representing 7 primary care domains: first contact (ie, accessibility and utilization); longitudinality (ie, ongoing care); coordination (ie, referrals and information systems); comprehensiveness (ie, services available and provided); family centeredness; community orientation; and cultural competence. Results: Having a primary care physician was significantly associated with patients reporting higher quality of primary care experiences. Specifically, relative to specialty care physicians, primary care physicians enhanced accessibility, achieved better community orientation and cultural competence, and provided more comprehensive services. Conclusions: In an area with universal health insurance and unrestricted physician choice, ambulatory patients of primary care physicians rated their medical care experiences as superior to those of patients of specialists. In addition to providing health insurance coverage, promoting primary care should be included as a health policy to improve patients’ quality of ambulatory medical care experiences.

Enhancing the measurement of health disparities for vulnerable populations.

This article presents a mechanism for tracking and reporting health disparities data that are based on a general model of vulnerability. We briefly discuss the origins of this model and describe its focus on the cumulative impact of multiple risk factors on health-related outcomes. We then demonstrate how the model can be applied to inform the collection and reporting of health disparities data by providing three examples. Since national and state datasets contain information on a wide range of risk factors, researchers and policy makers would benefit from examining the multiple risks that affect vulnerable populations simultaneously, as we have demonstrated in the three examples. These examples suggest that the determinants of health and healthcare problems are multifactorial and that they can be studied in an integrative approach using risk profiles. This research methodology can strengthen our existing knowledge of health disparities and aid in the recognition of points of intervention to successfully improve health and healthcare for vulnerable populations.

Assessing the impact of the Health Center Growth Initiative on health center patients.

Objectives. In 2001, the Health Center Growth Initiative was launched to increase access to primary health-care services through the expansion of the health center program. We examined the impact this initiative had on the number and types of patients seen by health centers, as well as the health center characteristics significantly associated with service expansions. Methods. We conducted secondary and time-trend analyses of the Uniform Data System, an annual dataset submitted to the Bureau of Primary Health Care by all federally qualified health centers. We performed trend and multi-variable analyses to examine the impact of the initiative on health center performance. Results. Health centers that received both new access points and expanded medical capacity funding saw the most rapid growth in patients. These centers experienced a 58% increase in total number of patients and a 60% increase in total number of encounters, compared with 10% and 8%, respectively, for centers receiving no funding at all. Conclusions were unchanged even after controlling for other health center characteristics. Conclusions. Public funding is critical to sustaining and expanding health center services to the nations vulnerable populations.