Community Tracking Study Household Survey Research Articles

Access disparity and health inequality of the elderly: unmet needs and delayed healthcare.

The purpose of this study is to investigate healthcare access disparity that will cause delayed and unmet healthcare needs for the elderly, and to examine health inequality and healthcare cost burden for the elderly. To produce clear policy applications, this study adapts a modified PRECEDE-PROCEED model for framing theoretical and experimental approaches. Data were collected from a large collection of the Community Tracking Study Household Survey 2003–2004 of the USA. Reliability and construct validity are examined for internal consistency and estimation of disparity and inequality are analyzed by using probit/ols regressions. The results show that predisposing factors (e.g., attitude, beliefs, and perception by socio-demographic differences) are negatively associated with delayed healthcare. A 10% increase in enabling factors (e.g., availability of health insurance coverage, and usual sources of healthcare providers) are significantly associated with a 1% increase in healthcare financing factors. In addition, information through a socio-economic network and support system has a 5% impact on an access disparity. Income, health status, and health inequality are exogenously determined. Designing and implementing easy healthcare accessibility (healthcare system) and healthcare financing methods, and developing a socio-economic support network (including public health information) are essential in reducing delayed healthcare and health inequality.

The effect of in-office waiting time on physician visit frequency among working-age adults

Disparities in unmet health care demand resulting from socioeconomic, racial, and financial factors have received a great deal of attention in the United States. However, out-of-pocket costs alone do not fully reflect the total opportunity cost that patients must consider as they seek medical attention. While there is an extensive literature on the price elasticity of demand for health care, empirical evidence regarding the effect of waiting time on utilization is sparse. Using the nationally representative 2003 Community Tracking Study Household Survey, the most recent iteration containing respondents' physician office visit frequency and estimated in-office waiting time in the United States (N = 23,484), we investigated the association between waiting time and calculated time cost with the number of physician visits among a sample of working-age adults. To avoid the bias that literature suggests would result from excluding respondents with zero physician visits, we imputed waiting time for the essential inclusion of such individuals. On average, respondents visited physician offices 3.55 times, during which time they waited 28.7 min. The estimates from a negative binomial model indicated that a doubling of waiting time was associated with a 7.7 percent decrease (p-value < 0.001) in physician visit frequency. For women and unemployed respondents, who visited physicians more frequently, the decrease was even larger, suggesting a stronger response to greater waiting times. We believe this finding reflects the discretionary nature of incremental visits in these groups, and a consequent lower perceived marginal benefit of additional visits. The results suggest that in-office waiting time may have a substantial influence on patients' propensity to seek medical attention. Although there is a belief that expansions in health insurance coverage increase health care utilization by reducing financial barriers to access, our results suggest that unintended consequences may arise if in-office waiting time increases.

The Association between Patient-Centered Attributes of Care and Patient Satisfaction

Little is known about the attributes of care that most strongly impact satisfaction in real-world settings where patients' limited medical knowledge may restrict their ability to ascertain the true quality of care. We therefore examined the association between patient-centered attributes of physician care (thoroughness, explanation, and listening), in-office waiting time, and patient satisfaction. We used the Community Tracking Study Household Survey, a US nationally representative dataset (n=71,594). Using logistic regression models, we analyzed the association between patient ratings of care attributes and patient satisfaction for the total sample and by subgroups, according to health status, physician type, and visit type. Patients' perception of excellent or very good care attributes was strongly associated with being very satisfied with care received (thoroughness of care, odds ratio [OR] 2.64, 95% confidence interval [CI] 2.31-3.02; listening, OR 2.04, 95% CI 1.77-2.36; explanation, OR 1.63, 95% CI 1.42-1.86), as was a waiting time of ≤10min (OR 1.50, 95% CI 1.39-1.63). The effect magnitude of thoroughness on satisfaction is particularly strong relative to high-quality listening and explanation among respondents in poor health, and for whom the most recent office visit was to see a generalist or for curative care. Thoroughness of care was the strongest determinant of patient satisfaction, followed by physician listening and explanation. Especially with patients' improved access to current medical information, it is important for physicians to recognize that excellent communication cannot serve as a substitute for high-quality, thorough care.

Frequent Emergency Department Use Among Released Prisoners With Human Immunodeficiency Virus: Characterization Including a Novel Multimorbidity Index

The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV). Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices. Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values. Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.

Exploring Differences in Trust in Doctors Among African American Men and Women

ObjectivesLow trust in doctors may partially account for African Americans' adverse health outcomes. Understanding the drivers of low trust can guide health care policy to improve trust and delivery of health care for African Americans. This study examines gender differences in trust in doctors among African Americans and explores factors differentially associated with low level trust for men vs women. Methodsand Measures: Cross-sectional analysis of 3649 African Americans using data from the 2003-2004 Community Tracking Study Household Survey, including 4 items measuring trust in doctors (range, 1 = lowest trust and 5 = highest trust). Items were assessed separately and as an index measure. Linear regression analyses adjusted for multiple con-founders and accounted for complex data sampling. ResultsOverall, men were less trusting of doctors than women. However, men differed from women only on 2 trust measures: "doctor influenced by insurance rules" (adjusted mean scores = 2.48 for men and 2.79 for women, p = .001) and "doctor performs unnecessary tests" (adjusted mean score = 4.00 for men and 4.28 for women, p = .010). Common correlates of low trust in men and women included less than high school education, age of at least 65 years, and having no usual source of care. Unique correlates of lower trust for men included rural living and no doctor visit in the preceding year. Unique correlates for women included low income and poorer health status. ConclusionsThere are differential predictors of low trust among African American men vs women, underscoring the need for gender-based and health care system-level approaches to improve African Americans' trust and health outcomes.

Gender Differences in Financial Hardships of Medical Debt

Women are more likely than men to forgo, delay, and ration medical care because of medical debt. Using 2003-04 Community Tracking Study Household Survey data, this study examined gender differences in five financial hardships associated with medical debt. Regression analyses accounting for predisposing, enabling, and need factors of health services use indicated women were less likely to report being contacted by a collection agency (b=-0.15, p<.05), using savings (b=-0.23, p<.005), or having any financial hardships associated with medical debt (b=-0.24, p<.05). There were no significant gender differences in putting off major purchases, borrowing money, and problems paying for necessities. Similarly, there were positive and negative relationships between medical debt financial hardships and income, insurance, and health status. Findings suggest that making health care affordable and equitable is critically important for both men and women. Research is needed to understand the differential impact of medical debt, especially among disadvantaged populations.

Disentangling the influence of socioeconomic status on differences between African American and white women in unmet medical needs.

We sought to disentangle the relationships between race/ethnicity, socioeconomic status (SES), and unmet medical care needs. Data from the 2003-2004 Community Tracking Study Household Survey were used to examine associations between unmet medical needs and SES among African American and White women. No significant racial/ethnic differences in unmet medical needs (24.8% of Whites, 25.9% of African Americans; P = .59) were detected in bivariate analyses. However, among women with 12 years of education or less, African Americans were less likely than were Whites to report unmet needs (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.42, 0.79). Relative to African American women with 12 years of education or less, the odds of unmet needs were 1.69 (95% CI = 1.24, 2.31) and 2.18 (95% CI = 1.25, 3.82) among African American women with 13 to 15 years of education and 16 years of education or more, respectively. In contrast, the relationship between educational level and unmet needs was nonsignificant among White women. Among African American women, the failure to recognize unmet medical needs is related to educational attainment and may be an important driver of health disparities, representing a fruitful area for future interventions.

Healthcare services accessibility of children in the USA

The increase in the number of children without access to healthcare services is an increasingly urgent issue in the United States. By using data from the Community Tracking Study Household Survey 1996 to 1997, we focus this study on the determinants that cause for the widening gap of healthcare service accessibility among children, 18 years and under, in the USA. Our empirical results suggest that factors such as the out-of-pocket price of healthcare services, household income, years of education by parent (or guardian), health insurance coverage, access to healthcare provider (availability of regular provider, obtaining an appointment, and travelling time) and provider–patient interaction strongly determine the actual use of outpatient services by children as realized access (i.e. accessibility).

Health communication difficulties and unmet medical needs: An exploratory study

This paper will explore how place of residence influences respondents' self-reported health communication difficulties (HCDs) and unmet medical needs (UMNs). Using data from the nationally representative 2003 Community Tracking Study (CTS) Household Survey, the study calculated the proportion of randomly selected respondents from 60 diverse communities, reporting HCDs and UMNs. The percentage of respondents per CTS site reporting HCDs and UMNs varied substantially. Overall, HCDs and UMNs were highly correlated with one another, although several CTS sites were incongruent on these measures. Despite geographic variation, there is a strong correlation between HCDs and UMNs.

Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?

The rise in emergency department (ED) use in the United States is frequently attributed to increased visits by the uninsured. We determine whether insurance status is associated with the increase in ED visits. Using the national Community Tracking Study Household Surveys from 1996 to 1997, 1998 to 1999, 2000 to 2001, and 2003 to 2004, we determined for each period the proportion of reported adult ED visits according to insurance status, family income, usual source of care, health status, and outpatient (non-ED) visits. Trends over time were tested for statistical significance. The proportion of adult ED visits by persons without insurance was stable across the decade. Uninsured individuals accounted for 15.5% of ED visits in 1996 to 1997, 16.1% in 1998 to 1999, 15.2% in 2000 to 2001, and 14.5% of visits in 2003 to 2004 (P for trend=.43). The proportion of visits by persons whose family income was greater than 400% of the federal poverty level increased from 21.9% to 29.0% (P=.002). The proportion of visits by those whose usual source of care was a physician's office increased from 52.4% in 1996 to 1997 to 59.0% in 2003 to 2004 (P=.002), whereas the proportion of visits by those without a usual source of care was essentially unchanged (9.7% of visits in 1996 to 1997 and 9.6% in 2003 to 2004; P=.74). The rise in ED visits between 1996 and 2003 cannot be primarily attributed to the uninsured. Major contributors to increasing ED utilization appear to be disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office.

Lack of Community Insurance and Mammography Screening Rates Among Insured and Uninsured Women

To evaluate whether the proportion of the local population without health insurance coverage is related to whether women undergo mammography screening. Survey data on 12,595 women 40 to 69 years of age from the 2000 to 2001 Community Tracking Study Household Survey were used to analyze the relation between community lack of insurance and whether the respondent had a mammogram within the past year. Women age 40 to 69 were less likely to report that they had a mammogram within the last year if they resided in communities with a relatively high uninsurance rate, even after adjusting for other factors. After adjusting for individual insurance and other factors, a 10-percentage-point decrease in the proportion of the local insured population is associated with a 17% (95% CI, 13% to 21%) decrease in the odds that a woman age 40 to 69 years will undergo mammography screening within a year. Women living in communities with high uninsurance are substantially less likely to undergo mammography screening. These results are consistent with the view that the negative impact of uninsurance extends to everyone in the community regardless of individual health insurance status.

Racial and Ethnic Disparities in the Use of Mental Health Services

The authors used data from the 1998-1999 Community Tracking Study (CTS) household survey to examine variations in predictors of use of mental health services among different racial and ethnic groups (white, African American, Hispanic, and other). African Americans and Hispanics were less likely to have visited a mental health professional (MHP) in the prior year than were whites. Independent of health insurance and health status, low- to middle-income African Americans may be at particular risk for inadequate use of an MHP compared to higher-income African Americans. Similarly, upper-income Hispanics were more likely to have visited an MHP than Hispanics in the lowest income range. Adults aged 50 and older were less likely to visit an MHP than individuals aged 18-49. Depressed men were more likely to visit an MHP than depressed women. Efforts to reduce disparities should focus on lower-income racial and ethnic minorities.

Physicians’ career satisfaction, quality of care and patients’ trust: the role of community uninsurance

There is evidence that health care providers located in communities with relatively large uninsured populations face financial difficulties because of low service demand and high levels of uncompensated care. Data on 4,920 physicians from the 2000-2001 Community Tracking Study Physician Survey and from 25,637 adults from the 2003 Community Tracking Study Household Survey were used to analyze whether the relative size of the local uninsured population is associated with the level of career satisfaction and the quality of care provided by physicians and to assess whether patient trust is associated with the level of community uninsurance. The results indicate that the proportion of uninsured adults in a given community is negatively related to physicians' career satisfaction and the perceived quality of health care provided. Community uninsurance is also negatively related to patient trust in their doctor and positively related to whether insured patients believed that their doctor was influenced by rules from health insurance companies. Physicians in communities with relatively large uninsured populations may have lower career satisfaction and lower perceptions of the quality of care provided due to financial difficulties. Patients in these communities are also less likely to trust their physician.

Differences Between Symptom-Specific and General Survey Questions of Unmet Need in Measuring Insurance and Racial/Ethnic Disparities in Access to Care

To examine differences in insurance and racial/ethnic disparities in access to care between a single-item measure of general unmet medical need and a multi-item measure of symptom-specific unmet medical need. The 2003 Community Tracking Study Household Survey, which included both a single question about any unmet medical needs over the last year, and a measure of unmet medical need keyed to the recent occurrence of 1 of 15 symptoms that a panel of physicians considered serious enough to warrant seeking medical care. We constructed 3 measures of unmet need (general perceived unmet need, perceived unmet need for a specific new symptom, and actual unmet need for the new symptom). We used multivariate logistic regression analysis to determine whether the measures have similar implications for access disparities by insurance status and by race/ethnicity, while controlling for income, health, and other sociodemographic characteristics. Uninsured people are consistently more likely than privately insured people to have unmet medical needs across the 3 measures of unmet need, and these differences were not due to differences in the perceived need for care. However, racial/ethnic disparities were apparent only for the symptom-specific measures of unmet need, and not the general measure of unmet need. Using a symptom-specific measure of unmet medical need is probably not worth the added survey complexity and cost if the primary objective is to measure access disparities by insurance coverage. However, a general measure of unmet medical needs may not adequately capture racial/ethnic disparities in access.

Why Do Hispanics Have So Little Employer-Sponsored Health Insurance?

This paper investigates low rates of employer health insurance coverage among Hispanics using national data from the Community Tracking Study Household Survey. Interview language served as a proxy for the degree of assimilation. Findings indicate that English-speaking Hispanics are more similar to whites in their labor market experiences and coverage than they are to Spanish-speaking Hispanics. Spanish-speakers' very low human capital (including their inability to speak English) results in much less access to job-based insurance. Though less important, Spanish-speaking Hispanics' demand for employer-sponsored insurance appears lower than that of English-speaking Hispanics or whites. Results suggest that language and job training may be the most effective way to bolster Hispanics' insurance coverage.

Congruent Satisfaction: Is There Geographic Correlation Between Patient and Physician Satisfaction?

Satisfaction among both physicians and patients is optimal for the delivery of high-quality healthcare. Although some links have been drawn between physician and patient satisfaction, little is known about the degree of satisfaction congruence among physicians and patients living and working in geographic proximity to each other. We sought to identify patients and physicians from similar geographic sites and to examine how closely patients' satisfaction with their overall healthcare correlates with physicians' overall career satisfaction in each selected site. We undertook a cross-sectional analysis of data from 3 rounds of the Community Tracking Study (CTS) Household and Physician Surveys (1996-1997, 1998-1999, 2000-2001), a nationally representative telephone survey of patients and physicians. We studied randomly selected participants in the 60 CTS communities for a total household population of 179,127 patients and a total physician population of 37,238. Both physicians and patients were asked a variety of questions pertaining to satisfaction. Satisfaction varied by region but was closely correlated between physicians and patients living in the same CTS sites. Physician career satisfaction was more strongly correlated with patient overall healthcare satisfaction than any of the other aspects of the healthcare system (Spearman's rank correlation coefficient 0.628, P<0.001). Patient trust in the physician was also highly correlated with physician career satisfaction (0.566, P<0.001). Despite geographic variation, there is a strong correlation between physician and patient satisfaction living in similar geographic locations. Further analysis of this congruence and examination of areas of incongruence between patient and physician satisfaction may aid in improving the healthcare system.

Do Determinants of Medicare Supplemental Coverage Choice Vary by Income?

Using data from the Community Tracking Study Household Survey (1998-99), we estimate the relationship between Medigap premiums and senior Medicare beneficiaries' supplemental coverage decisions. All seniors are more likely to be enrolled in an HMO in markets with higher Medigap prices. Lower income seniors are particularly sensitive to Medigap premiums and are more likely to have no supplemental coverage when faced with higher Medigap premiums. As Medicare supplemental options evolve in response to the 2003 Medicare Modernization Act, it is important to consider that lower income beneficiaries may respond to price changes and other factors differently than their higher income counterparts.

Insurance Premiums and Insurance Coverage of Near-Poor Children

States increasingly are using premiums for near-poor children in their public insurance programs (Medicaid/SCHIP) to limit private insurance crowd-out and constrain program costs. Using national data from four rounds of the Community Tracking Study Household Surveys spanning the seven years from 1996 to 2003, this study estimates a multinomial logistic regression model examining how public and private insurance premiums affect insurance coverage outcomes (Medicaid/SCHIP coverage, private coverage, and no coverage). Higher public premiums are significantly associated with a lower probability of public coverage and higher probabilities of private coverage and uninsurance; higher private premiums are significantly related to a lower probability of private coverage and higher probabilities of public coverage and uninsurance. The results imply that uninsurance rates will rise if both public and private premiums increase, and suggest that states that impose or increase public insurance premiums for near-poor children will succeed in discouraging crowd-out of private insurance, but at the expense of higher rates of uninsurance. Sustained increases in private insurance premiums will continue to create enrollment pressures on state insurance programs for children.

Does the market value racial and ethnic concordance in physician-patient relationships?

To determine if the market-determined earnings per hour of physicians is sensitive to the degree of area-level racial/ethnic concordance (ALREC) in the local physician labor market. 1998-1999 and 2000-2001 Community Tracking Study Physician Surveys and Household Surveys, 2000 U.S. Census, and the Area Resource File. Population-averaged regression models with area-level fixed effects were used to estimate the determinants of log earnings per hour for physicians in a two-period panel (N=12,886). ALREC for a given racial/ethnic group is measured as the percentage of physicians who are of a given race/ethnicity less the percentage of the population who are of the corresponding race/ethnicity. Relevant control variables were included. Average earnings per hour for Hispanic and Asian physicians varies with the degree of ALREC that corresponds to a physician's race/ethnicity. Both Hispanic and Asian physicians earn more per hour in areas where corresponding ALREC is negative, other things equal. ALREC varies from negative to positive for all groups. ALREC for Hispanics is negative, on average, due to the small percentage of the physician workforce that is Hispanic. This results in an average 5.6 percent earnings-per-hour premium for Hispanic physicians. However, ALREC for Asians is positive, on average, due to the large percentage of the physician workforce that is Asian. This results in an average 4.0 percent earnings-per-hour discount for Asian physicians. No similar statistically significant results were found for black physicians. The market-determined earnings per hour of Hispanic and Asian physicians are sensitive to the degree of ALREC in the local labor market. Larger sample sizes may be needed to find statistically significant results for black physicians.

Identifying affordable sources of medical care among uninsured persons.

To examine the effects of policy, health system, and sociodemographic characteristics on the likelihood that uninsured persons pay a lower price at their regular source of care, or that they are aware of lower priced providers in their community. The 2003 Community Tracking Study household survey, a nationally representative sample of the U.S. population and 60 randomly selected communities. The survey asked uninsured persons if they paid full or reduced cost at their usual source of medical care, or if they were aware of providers in their community that charge less for uninsured people. We use binomial and multinomial logistic regression analysis to examine the effects of various policy, health system, and sociodemographic characteristics on use and awareness of lower priced providers. We focus especially on the effects of safety-net capacity, measured by safety-net hospitals, community health centers, physicians' charity care, and Community Access Program (CAP) grants. Less than half of the uninsured (47.5 percent) reported that they used or were aware of a lower priced provider in their community. Multivariate regression analysis shows that greater safety-net capacity is associated with a higher likelihood of having a lower priced provider as the regular source of care and greater awareness of lower priced providers. Lower incomes and racial/ethnic minorities also had a higher likelihood of having a lower priced provider, although health status did not have statistically significant effects. Although increased safety-net capacity may lead to more uninsured having a lower priced provider, many uninsured who live near safety-net providers are not aware of their presence. Greater outreach designed to increase awareness may be needed in order to increase the effectiveness of safety-net providers in improving access to care for the uninsured.