Differences In Health Care Use Research Articles

Differences, Disparities, and Biases: Clarifying Racial Variations in Health Care Use

Studies documenting racial differences in health care use are common in the medical literature. However, observational studies of racial differences in health care use lack a framework for interpreting reports of variations in health care use, leading to various terms, ranging from "variations" to "bias," that suggest different causes, consequences, and, ultimately, remedies for such variations in treatment. We propose criteria to assess racial differences in health care use by using a clinical equity (equal treatment based on equal clinical need) framework. This framework differentiates between initial reports of racial differences and subsequent classifications of their findings as racial disparities or racial bias in health care use. Racial variations in health care use may be considered disparities after demonstrating that racial differences are not attributable to treatment eligibility, clinical contraindications, patient preferences, or confounding by other clinical factors and are associated with adverse consequences. Racial bias with adverse consequences in health care may be inferred if a racial variation in treatment that has been characterized as a disparity persists after accounting for health care system factors (for example, type of hospital at which the patient was treated). We apply this framework to published reports of racial differences in treatment to determine which studies provide evidence of differences, disparities, and bias. We discuss the use of such a framework in directing policy interventions for alleviating inappropriate racial variations in health care use.

A culturally sensitive health care practice model--theory construction and its testing.

The major purpose of this paper was to develop a model for the use of complementary and alternative health care options. Chinese-American families were selected due to their large proportion among all ethnic populations in the United States. Andersen's (1973 and 1995) perception of predisposing and enabling was adopted to test study variables singly and interactively on their health care use. The dependent variable was defined as health behavior preference towards Chinese treatment (also known as complementary and alternative medicine treatment) or Western treatment, and a combination of Chinese and Western treatment (also known as integrative medicine treatment). Data were randomly collected from 240 adult Chinese-American respondents out of 1080 members of the Chinese American Association in the greater Cleveland area. Findings both in the full and partial research models reveal that the factors contributing the most to their medical preferences were their acculturation level and health beliefs. Inter-generational differences in health care use were also discussed.

Race/ethnic differences in health care use for orofacial pain among older adults.

The purpose of this study was to describe race/ethnic differences in the use of formal health care services for painful oral symptoms by older adults. We also considered the sex of the respondent rather than assuming that males and females within a specific racial group would use health care services similarly. To our knowledge, these specific utilization patterns have never been reported before in the pain literature.Telephone interviews were conducted on a stratified random sample of 1,636 community dwelling older (65+) north Floridians. A total of 5,860 households were contacted and screened, with 75.3% participating to the point where their eligibility for the study could be determined. Overall race/ethnic differences in patterns of health care use for orofacial pain were not found. However, when we stratified race/ethnicity by sex, Black females (37.6%) were the least likely to have visited a health care provider, followed by non-Hispanic White females (47.2%), non-Hispanic White males (49.3%), and Black males (62.7%). Point estimates of odds ratio, adjusting for financial differences, indicate that more non-Hispanic White males (OR=1.79) and Black males (OR=2.74) visited a health care provider than Black females. Our results also suggest that for older Black adults, financial constraints have a more significant impact on decisions about health care for orofacial pain than they do for non-Hispanic Whites. For non-Hispanic White respondents, characteristics of the pain symptoms were significant determinates of health care use for their painful oral symptoms. Pain at its worst was a positive predictor for four of the five analyses (jaw joint pain, painful oral sores, temperature sensitivity, and toothache pain). The duration variable (years with pain) was a negative predictor of health care use. This is consistent with the conclusion that individuals seek care early in the course of the symptom, i.e. an active care seeking phase, make emotional or physical adjustments, and then resign themselves to the symptoms.

An explanatory model of medical practice variation: a physician resource demand perspective.

Practice style variation, or variation in the manner in which physicians treat patients with a similar disease condition, has been the focus of attention for many years. The research agenda is further intensified by the unrealistic assumption that by reducing variation, quality will be improved, costs will be reduced, or both. There is a wealth of literature that identifies differences in health care use of many kinds, in apparently similar communities. Attempts have been made by many scholars to identify the determinants of variation in terms of differences in the population characteristics (e.g. age, sex, insurance, etc.) and geographical characteristics (e.g. distance to provider, number of physicians, number of hospital beds, etc.). When significant differences in use rates prevail after controlling for differences in population characteristics, it is often attributed to 'uncertainty', or the fact that there is no consensus on what constitutes the optimum treatment process. It is suggested by this literature that the greatest variation can be found in the circumstances where there is the most 'uncertainty'. In this work, a physician resource demand model is proposed in which it is suggested that, during the diagnosis and treatment process, physicians demand resources consistent with the clinical needs of the patients, modified by the intervening forces under which they practice. These intervening forces, or constraints, are categorized as patient agency constraints, organizational constraints and environmental constraints, which are characterized as 'induced variation'. It is suggested that when all of the variables that constitute these constraints are identified, the remaining variance represents 'innate variance', or practice style differences. It is further suggested that the more completely this model is specified, the more likely area differences will be attenuated and the smaller will be the residual variance.

Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes.

This study ascertained the odds of diagnosed depression in individuals with diabetes and the relation between depression and health care use and expenditures. First, we compared data from 825 adults with diabetes with that from 20,688 adults without diabetes using the 1996 Medical Expenditure Panel Survey (MEPS). Second, in patients with diabetes, we compared depressed and nondepressed individuals to identify differences in health care use and expenditures. Third, we adjusted use and expenditure estimates for differences in age, sex, race/ethnicity, health insurance, and comorbidity with analysis of covariance. Finally, we used the Consumer Price Index to adjust expenditures for inflation and used SAS and SUDAAN software for statistical analyses. Individuals with diabetes were twice as likely as a comparable sample from the general U.S. population to have diagnosed depression (odds ratio 1.9, 95% CI 1.5-2.5). Younger adults (<65 years), women, and unmarried individuals with diabetes were more likely to have depression. Patients with diabetes and depression had higher ambulatory care use (12 vs. 7, P < 0.0001) and filled more prescriptions (43 vs. 21, P < 0.0001) than their counterparts without depression. Finally, among individuals with diabetes, total health care expenditures for individuals with depression was 4.5 times higher than that for individuals without depression ($247,000,000 vs. $55,000,000, P < 0.0001). The odds of depression are higher in individuals with diabetes than in those without diabetes. Depression in individuals with diabetes is associated with increased health care use and expenditures, even after adjusting for differences in age, sex, race/ethnicity, health insurance, and comorbidity.

Linkage of the Canadian Study of Health and Aging to Provincial Administrative Health Care Databases in Nova Scotia

The Canadian Study of Health and Aging (CSHA) was a cohort study that included 528 Nova Scotian community-dwelling participants. Linkage of CSHA and provincial Medical Services Insurance (MSI) data enabled examination of health care utilization in this subsample. This article discusses methodological and ethical issues of database linkage and explores variation in the use of health services by demographic variables and health status. Utilization over 24 months following baseline was extracted from MSI's physician claims, hospital discharge abstracts, and Pharmacare claims databases. Twenty-nine subjects refused consent for access to their MSI file; health card numbers for three others could not be retrieved. A significant difference in healthcare use by age and self-rated health was revealed. Linkage of population-based data with provincial administrative health care databases has the potential to guide health care planning and resource allocation. This process must include steps to ensure protection of confidentiality. Standard practices for linkage consent and routine follow-up should be adopted. The Canadian Study of Health and Aging (CSHA) began in 1991-92 to explore dementia, frailty, and adverse health outcomes (Canadian Study of Health and Aging Working Group, 1994). The original CSHA proposal included linkage to provincial administrative health care databases by the individual CSHA study centers to enhance information on health care utilization and outcomes of study participants. In Nova Scotia, the Medical Services Insurance (MSI) administration, which drew the sampling frame for the original CSHA, did not retain the list of corresponding health card numbers. Furthermore, consent for this access was not asked of participants at the time of the first interview. The objectives of this study reported here were to examine the feasibility and ethical considerations of linking data from the CSHA to MSI utilization data, and to explore variation in health services use by demographic and health status characteristics in the Nova Scotia community cohort.

Does gender bias exist in the use of specialist health care?

To investigate the evidence for the existence of gender bias (defined as care provided independently of clinical need) in the use of specialist services by critically appraising the literature. A computer-assisted search of the bibliographic databases PubMed, Medline, EMBASE, Healthstar and Social Science Citation Index for English language papers published from 1966 until May 1999. In addition, four journals were handsearched and the reference lists of identified papers were explored. Retrospective studies were only used when there were insufficient prospective studies. One hundred and thirty-eight studies were identified covering five major topics: coronary artery disease; renal transplantation; human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS); mental illness; and other (mainly invasive) procedures. The majority (94) examined coronary artery disease. It appears that men are more likely to undergo non-invasive investigations than women, but that subsequent investigation and treatment shows no clear evidence of gender differences. Men are more likely to undergo renal transplantation and, for those with HIV and AIDS, to receive azidothymidine (zidovudine, AZT) than women. There are some indications that disparities in favour of men also occur for those suffering from cardiac arrhythmias and cerebrovascular disease, and for those undergoing vascular surgery, hip replacement and heart transplantation. In contrast, women are more likely to undergo liver transplantation and cataract surgery. Mental health services may be provided differently for men and women. All these findings are limited by a lack of accurate denominator information and insufficient ability to adjust for prognostic factors. Differences in health care use can be due to demand factors (e.g. differences in the prevalence and severity of disease or in patient preferences), supply factors (particularly clinical judgement), or both. There is a need to examine these explanations thoroughly for gender inequalities in order to ensure that equity (lack of bias) is achieved. There is also a need for higher quality studies if differences are to be attributed conclusively to bias or not.

Adolescent gender differences in health care use & services provided: Are male adolescents being seen?

Adolescent gender differences in health care use & services provided: Are male adolescents being seen?

Discriminant Analysis of Medical-Care Use Among Shipboard U.S. Navy Men and Women

A matched sample of men and women in the US. Navy (N = 1,068) were examined in a study of shipboard medical-care use. The instrument used in this study is theoretically based on the Health Beliefs Model (HBM). Theoretically, the HBM attempts to explain health-seeking behavior by describing the antecedent conditions within the individual. Preliminary chi-square results indicate statistically significant gender differences in health-care use. Separate discriminant function analyses were employed for men and women. Results for each separate discriminant function analysis yielded a single statistically significant function for female crewmembers only. Univariate F-ratio results between female medical users and nonusers show that users have significantly higher ratings of health value, health comparison, and “reason” barriers (e.g., “I already see the doctor a lot”). Male users and nonusers differ in that users have significantly higher ratings of medical-care satisfaction, whereas nonusers have significantly higher “motivation” barriers. Implications of these findings and the efficacy of the HBM are discussed.

Gender differences in health care use: Are male adolescents being seen? 25

Background: Adult males use health services less often than females; these gender differences likely begin in adolescence but are not well studied.

Health effects of unemployment—I. Long-term unemployed men in a rural and an urban setting

Between 1983 and 1987 in an urban and a rural Dutch area employed and long-term unemployed men, between 30 and 50 years old, have been interviewed. The main topics of the study were the independent health effects of unemployment, the factors related to these health effects and socio-culural differences. Long-term unemployment is considered to be a social phenomenon that restructures individual's social positions into multiple deprived positions. The characteristics of this restructuring are a relative lack of socio-structural resources, low social participation and emotional problems. Independent effects on the health status (perceived somatic and depressive complaints and self reported chronic disease) have been found to exist among both the rural and the urban unemployed. There is no clear effect of unemployment on health care use, but regional differences in health care use among rural and urban unemployed have been found. Between the urban and rural unemployed there are more similarities than differences in the factors and models explaining ill-health. The most important factors are: loneliness, disadvantageous consequences of unemployment, money worries and ill-health prior to jobloss (health selection at the labour market). One important difference is that among the urban unemployed the perceived size of the network is an explanatory factor, but among the rural unemployed perceived stigmatization is more important. In general, ill-health can be better explained for the rural unemployed than for the urban unemployed.