Regular Source Of Medical Care Research Articles

HIV-1 RNA viral load monitoring in HIV-infected drug users on antiretroviral therapy: relationship with outpatient care patterns.

HIV-1 viral load (VL) testing is a standard component of HIV care. We examined the use and predictors of VL testing in drug users, a group at risk for problematic care. Using 1996 to 1998 New York State (NYS) Medicaid files, we studied drug users who had been enrolled >10 months, had been prescribed antiretroviral agents in 1997 and 1998, and who had undergone any VL testing in 1997. Our outcome was regular VL testing shown by two or more paid claims for this test in 1998. Patterns of care in 1997 were defined as: regular source of medical care (>35% of visits to one provider), and/or regular drug treatment of >6 months, or neither. We counted visits in 1997 to a provider offering HIV-focused care. Adjusted odds ratios (AORs) of VL testing were assessed. Of 3131 drug users, 73.9% had at least one VL test, whereas 56.2% had two or more VL tests in 1998. The AORs of two or more VL tests were increased for those with regular drug abuse care alone (AOR, 1.50; 95% confidence interval [CI], 1.21-1.84) or with regular medical care (AOR, 1.27; 95% CI, 1.03-1.57) versus those with neither. HIV-focused care was positively associated with two or more VL tests (AOR, 1.38; 95% CI, 1.05-1.81 for 1-3 visits; AOR, 1.94; 95% CI, 1.50-2.51 for four or more visits). We found that nearly half this cohort of drug users did not have regular VL testing. Drug users with HIV-focused care or with regular drug treatment are more likely to have regular VL testing.

Provision of influenza and pneumococcal vaccines to injection drug users at a syringe exchange.

The objective of this study was to evaluate the feasibility, acceptance, and utility of administering influenza and pneumococcal vaccines to active injection drug users at a syringe exchange program (SEP) in New York City. Influenza and pneumococcal vaccines were offered for 1 month. Data on demographics, health status, vaccine awareness, and prior vaccination status were collected using a staff-administered questionnaire. Of 199 participants interviewed 167 (86%) agreed to one or both vaccinations; 24% of study participants had a chronic condition for which vaccination was indicated and 53% had no regular source of medical care; 95% were aware of influenza vaccine while 25% were aware of pneumococcal vaccine (p <.0001). Of those offered the influenza vaccine, 86% accepted it and 70% of those offered pneumococcal vaccine accepted it (p <.001). Influenza and pneumococcal vaccinations were well-accepted by active drug users at a syringe exchange although there was both greater awareness of and acceptance of influenza. Many SEP participants with chronic medical conditions for which these vaccines are indicated did not have a regular source of health care. Syringe exchange programs may be valuable sites to administer respiratory vaccines and other public health interventions to drug injectors not engaged in medical care in other settings.

The state of public health genetics in Rhode Island

Rhode Island is a small state, with a population of approximately one million; 11% live below the poverty line; 10% are uninsured; 10% are minorities; and 13% have no regular source of medical care. There are approximately 77,000 children under the age of 6 years; 20% live in poverty. As reported by vital records, the state has approximately 13,000 births per year; 3.2% have congenital anomalies; less than 1% have inborn errors of metabolism or hemoglobinopathies; but 41% are deemed at developmental risk. There are a total of 1,900 children in the RI Department of Health's early intervention program. One of the departmental goals is to ensure that all children with special health care needs receive diagnostic, therapeutic, and habilitative services on a timely basis. Towards this end, the department has established a new initiative to integrate genetics in public health, utilizing both existing and new sources of funding (from the Maternal and Child Health Bureau of Healthcare Resources and Services Administration). A novel information infrastructure will be implemented to identify children with such needs; identify health resources and services in use; generate aggregate data for surveillance, needs assessment, planning, and evaluation; generate profiles for tracking and followup services; and provide patient information to pediatric and specialty physicians. All of the above will be achieved through a universal, longitudinal, child health information database (KIDSNET), which is linked to 18% of pediatric medical-care sites in the state, and serves more than half of the children in the system. A revised state genetics plan is currently being written to incorporate all relevant elements, with special emphasis on genetics education for consumers, nongeneticist healthcare professionals and members of the legislature.

Commentary on caring for the uninsured and underinsured.

JAMA Impact of a Children's Health Insurance Program on Newly Enrolled Children Judith R. Lave, PhD; Christopher R. Keane, ScD, MPH; Chyongchiou J. Lin, PhD; Edmund M. Ricci, PhD; Gabriele Amersbach, MA; Charles P. LaVallee Context. —Although there is considerable interest in decreasing the number of US children who do not have health insurance, there is little information on the effect that health insurance has on children and their families. Objective. —To determine the impact of children′s health insurance programs on access to health care and on other aspects of the lives of the children and their families. Design. —A before-after design with a control group. The families of newly enrolled children were interviewed by telephone using an identical survey instrument at baseline, at 6 months, and at 12 months after enrollment into the program. A second group of families of newly enrolled children were interviewed 12 months after the initial interviews to form a comparison sample. Setting. —The 29 counties of western Pennsylvania, an area with a population of 4.1 million people. Subjects. —A total of 887 families of newly enrolled children were randomly selected to be interviewed; 88.3% agreed to participate. Of these, 659 (84%) responded to all 3 interviews. The study population consists of 1031 newly enrolled children. The children were further classified into those who were continuously enrolled in the programs. The 330 comparison families had 460 newly enrolled children. Main Outcome Measures. —The following access measures were examined: whether the child had a usual source of medical or dental care; the number of physician visits, emergency department visits, and dentist visits; and whether the child had experienced unmet need, delayed care, or both for 6 types of care. Other indicators were restrictions on the child′s usual activities and the impact of being insured or uninsured on the families. Results. —Access to health care services after enrollment in the program improved: at 12 months after enrollment, 99% of the children had a regular source of medical care, and 85% had a regular dentist, up from 89% and 60%, respectively, at baseline. The proportion of children reporting any unmet need or delayed care in the past 6 months decreased from 57% at baseline to 16% at 12 months. The proportion of children seeing a physician increased from 59% to 64%, while the proportion visiting an emergency department decreased from 22% to 17%. Since the comparison children were similar to the newly enrolled children at enrollment into the insurance programs, these findings can be attributed to the program. Restrictions on childhood activities because of lack of health insurance were eliminated. Parents reported that having health insurance reduced the amount of family stress, enabled children to get the care they needed, and eased family burdens. Conclusions. —Extending health insurance to uninsured children had a major positive impact on children and their families. In western Pennsylvania, health insurance did not lead to excessive utilization but to more appropriate utilization. Arch Ophthalmol 1998;279:1820-1825.

An event count model for studying health services utilization.

The purpose of this article is to first conceptualize health services utilization behavior as event counts. Based on this concept and behavioral theory, the author presents the Generalized Event Count model as an alternative modeling tool for studying health services utilization. This model is theory driven and is consistent with behavioral assumptions. In presenting the Generalized Event Count model, the author first examines its model assumptions to see whether they conform to elements of behavior theory, assumptions of health services utilization, and the distribution assumption of the nature of the data. To demonstrate the Generalized Event Count model, the author applied this model to an empirical ambulatory care utilization data set from a 1988 household interview of Chinese-Americans in Boston's inner-city community. The Generalized Event Count model analysis suggested that the regular source of medical care and the use of Chinese medicine were strong predictors of physician visits for this population. Further, the Generalized Event Count model was able to test that most of the ambulatory visits within an individual were correlated. Compared with other models, the Generalized Event Count model is more consistent with health services utilization behavioral assumptions. Moreover, it makes an efficient use of information from the utilization data for model estimation. This model has the potential of having broad applications in studying various types of health services utilization, especially for analyzing cross-sectional utilization data.

Health care access and seven-year change in cigarette smoking: The CARDIA study

Objectives: To determine associations among health care access, cigarette smoking, and change in cigarette smoking status over 7 years. Methods: A cohort of 4,086 healthy young adults was followed from 1985–1986 through 1992–1993. Participants were recruited from four urban sites balanced on gender, race (African Americans and whites), education (high school or less, and more than high school), and age (18–23 and 24–30). Outcome measures were smoking status at Year 7, as well as 7-year rates of smoking cessation and initiation. Results: For each of three access barriers reported at Year 7 (lack of health insurance, lack of regular source of medical care, and expense), participants experiencing the barrier had a higher prevalence of smoking, quit smoking less frequently, and started smoking more frequently; e.g., only 15% of participants with health insurance lapses quit smoking over the 7-year period, compared with 26% of those with insurance ( P < 0.001). Results were similar for each race/gender stratum, and persisted after adjustment for usual markers of socioeconomic status: education, income, employment, and marital status. Conclusions: Health care access was associated with lower prevalence of smoking and beneficial 7-year changes in smoking, independent of socioeconomic status. The possibility that this is a causal relationship has implications in the prevention of cardiovascular disease, cancer and multiple other smoking-related diseases, and deserves further exploration.

Impact of a children's health insurance program on newly enrolled children.

Although there is considerable interest in decreasing the number of US children who do not have health insurance, there is little information on the effect that health insurance has on children and their families. To determine the impact of children's health insurance programs on access to health care and on other aspects of the lives of the children and their families. A before-after design with a control group. The families of newly enrolled children were interviewed by telephone using an identical survey instrument at baseline, at 6 months, and at 12 months after enrollment into the program. A second group of families of newly enrolled children were interviewed 12 months after the initial interviews to form a comparison sample. The 29 counties of western Pennsylvania, an area with a population of 4.1 million people. A total of 887 families of newly enrolled children were randomly selected to be interviewed; 88.3% agreed to participate. Of these, 659 (84%) responded to all 3 interviews. The study population consists of 1031 newly enrolled children. The children were further classified into those who were continuously enrolled in the programs. The 330 comparison families had 460 newly enrolled children. The following access measures were examined: whether the child had a usual source of medical or dental care; the number of physician visits, emergency department visits, and dentist visits; and whether the child had experienced unmet need, delayed care, or both for 6 types of care. Other indicators were restrictions on the child's usual activities and the impact of being insured or uninsured on the families. Access to health care services after enrollment in the program improved: at 12 months after enrollment, 99% of the children had a regular source of medical care, and 85% had a regular dentist, up from 89% and 60%, respectively, at baseline. The proportion of children reporting any unmet need or delayed care in the past 6 months decreased from 57% at baseline to 16% at 12 months. The proportion of children seeing a physician increased from 59% to 64%, while the proportion visiting an emergency department decreased from 22% to 17%. Since the comparison children were similar to the newly enrolled children at enrollment into the insurance programs, these findings can be attributed to the program. Restrictions on childhood activities because of lack of health insurance were eliminated. Parents reported that having health insurance reduced the amount of family stress, enabled children to get the care they needed, and eased family burdens. Extending health insurance to uninsured children had a major positive impact on children and their families. In western Pennsylvania, health insurance did not lead to excessive utilization but to more appropriate utilization.

Demographic Characteristics of Persons Without a Regular Source of Medical Care--Selected States, 1995

Having a regular source of medical care (i.e., a regular provider or site) is one of the strongest predictors of access to health-care services, which has been associated with greater use of preventive health services. This report summarizes state-specific data from the 1995 Behavioral Risk Factor Surveillance System (BRFSS) and examines demographic factors associated with not having a regular source of medical care among adults in the 10 states for which this information was available. The findings indicate that certain demographic characteristics are associated with lack of a regular source of medical care.

Medical status of adolescents at time of admission to a juvenile detention center

To examine the medical status and history of health care utilization of adolescents at the time of their admission to a juvenile detention facility. Data were collected over an 18-month period on all detainees admitted for the first time to a juvenile detention facility in a major southeastern city in the United States. Information was gathered through a private, confidential interview completed by a medical social worker and a physical examination by a physician. Information was obtained regarding past medical history, complaints at the time of admission, health care utilization, and physical examination. Approximately 10% of teenagers admitted to a detention facility have a significant medical problem (excluding drug/alcohol abuse, or uncomplicated sexually transmitted diseases) that requires medical follow-up. The majority of these conditions were known to the adolescent at the time of admission. Only a third of adolescents admitted to the detention facility reported a regular source of medical care, and only about 20% reported having a private physician. A majority of all the detainees had already fallen behind in or dropped out of school. More than half of the families of the adolescents with a medical problem appeared to be unable or unwilling to assist in ensuring proper medical follow-up. A significant percentage of adolescents entering a detention facility have a medical problem requiring health care services. Detention facilities offer an opportunity to deliver and coordinate medical care to high-risk adolescents. Programs linking public and private health care providers with the correctional care system may provide juveniles with an acceptable option for obtaining needed health care services.

Assessment of an Adult Population's Knowledge Regarding Vaccine-Preventable Diseases.

Background: The purpose of this study was to determine adult patients' knowledge about their history of age-appropriate routine vaccinations and vaccine preventable diseases. Methods: This was a prospective descriptive study using a self-administered questionnaire. During a 9-month period, all patients older than 18 years of age answered a questionnaire at the time of their first visit to a health department travelers' clinic. Questions included knowledge of vaccines that they might have received (against tetanus, diphtheria, polio, measles, rubella, influenza, and pneumococcus); knowledge of illnesses that they might have had (measles and rubella); incidence of visits to a regular physician; and incidence of chronic illness. Results: Two hundred and twenty patients answered the questionnaire. Eighty-two percent had a regular physician whom they had visited within 5 years. Respondents reported their age-appropriate vaccination history as follows: Td-69%; polio-48%; measles-41%; rubella-38%; influenza-68%; and pneumococcal-13%. For any vaccine, approximately one-third of respondents did not know their status. Age, gender, or a regular source of medical care did not influence the results. Conclusions: Adult patients frequently did not receive, or do not know whether they received, recommended immunizations. Until physicians giving primary medical care improve patient education about vaccination status and develop a better system for having patients keep records of their routine vaccinations, travel clinics will have to function, in part, as primary health care providers.

Use of Perinatal and Infant Health Services by Mexican-American Medicaid Enrollees

Objectives. —Lack of health insurance and a regular source of medical care are barriers affecting use of health services by Mexican Americans. We studied perinatal and infant health service use by Mexican-American women and non-Hispanic white women and their infants enrolled in Arizona's Medicaid program and explored characteristics associated with use of health services. Design. —A descriptive comparative study that used data collected from office records, birth certificates, and household interviews. Setting. —Participants resided in the state's most populous county and were enrolled in the Arizona Health Care Cost Containment System, a health maintenance organization—oriented Medicaid demonstration project. Subjects. —Random sample of 308 Mexican-American mother-infant dyads and 312 non-Hispanic white mother-infant dyads. The women were enrolled before the sixth month of pregnancy and for 60 days post partum; their infants were continuously enrolled throughout their first year. Outcome Measures. —Timing and number of prenatal visits and a modified Kessner Index, postpartum visits, number and purpose of office visits during the infants' first year, and immunizations received. Results. —Mexican Americans averaged fewer prenatal visits than non-Hispanic whites (8.6 vs 10.2 visits) and were less likely to have care (41.1% vs 52.8%). Both groups of mothers are well below the 68% of women nationally who receive adequate prenatal care. Controlling for important socioeconomic status and cultural characteristics, ethnicity had a strong independent effect on the number of prenatal visits and adequacy of prenatal care. Mexican-American infants made fewer visits (8.2 vs 9.8) and completed fewer age-appropriate immunizations than non-Hispanic whites. Conclusions. —Health insurance and a regular source of care are insufficient conditions for ensuring adequate use of maternal and child health services by Mexican-American Medicaid enrollees. Factors associated with their less frequent use of these preventive health services include higher numbers of children, transportation problems, and less assistance from their support system. ( JAMA . 1994;272:297-304)

Decategorizing health services: interim findings from the Robert Wood Johnson Foundation's Child Health Initiative.

Although results from the evaluation are preliminary thus far, certain tentative conclusions can be reached. First, both care coordination on a small scale and the production of community health report cards are achievable within the relatively short life of a foundation grant. Moreover, both efforts can result in tangible improvements for children and their families. Report cards associated with the initiative have made children's issues more prominent and appear to have led many community leaders to focus greater attention on children's needs. Likewise, many of the care coordination systems developed under the initiative have produced real change for children and their families by guiding them to needed health care and other services. It is important, however, to keep these accomplishments in perspective. While of significant benefit to demonstration communities, the monitoring and care coordination components of this initiative are not unique. A large number of communities have adopted monitoring and reporting programs in recent years. Similarly, care coordination efforts are well established in many communities. What is unique about the RWJF initiative is its attempt at decategorization, and much less progress has been demonstrated for this component. The less-than-hoped-for progress in implementing decategorization at the original sites appears to be the product of a number of interrelated factors. These include an absence of existing models and appropriate technical assistance; political difficulties in gaining cooperation from multiple local agencies involved in service provision; limited progress in establishing needed connections with the state and federal agencies that have authority over categorical programs; and difficulties in implementing major programatic changes when the health care system itself is undergoing rapid change. In combination, these barriers have proven to be largely insurmountable for the originally funded sites, although it is too early in the project to determine which of these factors is predominantly responsible for the lack of success. Whether the newer sites can learn from the experience of the first group and adapt strategies to overcome the multiple hurdles involved remains to be seen. Decategorization is a tool that has the potential to rationalize a fragmented service system by facilitating the coordination of services, especially for children and families with multiple needs. The need for decategorization of funds will not disappear, even if the federal government chooses to combine more of its grant programs to the states into block grants.(ABSTRACT TRUNCATED AT 400 WORDS)

Use of Perinatal and Infant Health Services by Mexican-American Medicaid Enrollees

Lack of health insurance and a regular source of medical care are barriers affecting use of health services by Mexican Americans. We studied perinatal and infant health service use by Mexican-American women and non-Hispanic white women and their infants enrolled in Arizona's Medicaid program and explored characteristics associated with use of health services. A descriptive comparative study that used data collected from office records, birth certificates, and household interviews. Participants resided in the state's most populous county and were enrolled in the Arizona Health Care Cost Containment System, a health maintenance organization-oriented Medicaid demonstration project. Random sample of 308 Mexican-American mother-infant dyads and 312 non-Hispanic white mother-infant dyads. The women were enrolled before the sixth month of pregnancy and for 60 days post partum; their infants were continuously enrolled throughout their first year. Timing and number of prenatal visits and a modified Kessner Index, postpartum visits, number and purpose of office visits during the infants' first year, and immunizations received. Mexican Americans averaged fewer prenatal visits than non-Hispanic whites (8.6 vs 10.2 visits) and were less likely to have "adequate" care (41.1% vs 52.8%). Both groups of mothers are well below the 68% of women nationally who receive adequate prenatal care. Controlling for important socioeconomic status and cultural characteristics, ethnicity had a strong independent effect on the number of prenatal visits and adequacy of prenatal care. Mexican-American infants made fewer visits (8.2 vs 9.8) and completed fewer age-appropriate immunizations than non-Hispanic whites. Health insurance and a regular source of care are insufficient conditions for ensuring adequate use of maternal and child health services by Mexican-American Medicaid enrollees. Factors associated with their less frequent use of these preventive health services include higher numbers of children, transportation problems, and less assistance from their support system.

Obstacles Predicting Lack of a Regular Provider and Delays in Seeking Care for Patients at an Urban Public Hospital

To determine the correlation among obstacles to medical care, lack of a regular source of care, and delays in seeking care. Cross-sectional survey of patients presenting for ambulatory care during a 7-day period. Multiple logistic regression models were used to identify obstacles independently associated with outcome variables. Urban public hospital. A total of 3897 disadvantaged and predominantly minority patients. Lack of a regular source of medical care and delay in seeking medical care for a new problem. The majority (61.6%) of patients reported no regular source of care. Of 2341 patients reporting a new medical problem, 48.4% waited more than 2 days before seeking medical care. No health insurance (adjusted odds ratio [OR], 2.2; 95% confidence interval [CI], 1.89 to 2.61), no transportation (OR, 1.44; 95% CI, 1.23 to 1.70), exposure to violence (OR, 1.21; 95% CI, 1.08 to 1.45), and living in a supervised setting (OR, 1.50; 95% CI, 1.00 to 2.25) were independent predictors of lack of a regular source of care. No insurance (OR, 1.24; 95% CI, 1.02 to 1.51), no transportation (OR, 1.45; 95% CI, 1.19 to 1.77), and less than a high school education (OR, 1.22; 95% CI, 1.08 to 1.49) were independent predictors of delaying care for a new medical problem. Obstacles in addition to lack of insurance impede provision of medical care to disadvantaged patients. The adoption of universal health care coverage alone will not guarantee access to appropriate medical care.

Physician utilization and urban native people in Saskatoon, Canada

This paper compares the physician utilization patterns of similarly disadvantaged urban native and non-native people in the western Canadian city of Saskatoon. Through the administration of a large survey instrument to 142 native and 84 non-native respondents, the author demonstrates the extensive utilization by native residents of a particular ‘walk-in’ clinic located in the area which has come to be viewed by many natives as their regular source of medical care. Non-natives, in contrast, demonstrated a greater utilization of physicians in private practice. Beyond the actual location of the physician providing the service, the data demonstrate few differences between natives and non-natives in the extent of their physician utilization. The paper suggests that socio-economic rather than cultural factors better explain the observed patterns of behaviour.

Hypertension Management in the Multiple Risk Factor Intervention Trial (MRFIT)

The Multiple Risk Factor Intervention Trial was a large collaborative primary prevention trial designed to test the effects of lowering cardiovascular risk factors (ie, diastolic blood pressure [DBP], serum cholesterol, and cigarette smoking) on mortality rate from coronary heart disease in 12,866 high-risk men aged 35 to 57 years. Men were randomly assigned to either special intervention (SI) or usual care (UC) groups. Usual care men were referred to their regular source of medical care. Special intervention men were seen frequently and underwent intensive intervention initially followed by maintenance intervention in 22 different clinical centers. Hypertension intervention in SI men primarily consisted of a stepped-care pharmacologic approach designed to lower blood pressure (BP). After six years, 58.2% of SI men and 47.0% of UC men were given antihypertensive medication. In both study groups, mean systolic and diastolic BPs decreased from baseline; after six years, overall DBP was 3.2 mm Hg lower in SI men compared with UC men. In hypertensive men (DBP greater than or equal to 90 mm Hg or those taking antihypertensive medication at baseline), after six years, DBP was 4.4 mm Hg lower in the SI group compared with the UC group. Use of specific antihypertensive agents differed substantially between the two groups. Self-reported complaints while taking antihypertensive drugs were minimal in both groups. Weight loss was associated with BP lowering in both study groups, regardless of treatment status.

Importance of a regular source of medical care among the elderly.

In recent years health services researchers have become increasingly aware of the importance of a regular doctor to whom the patient usually goes when sick or in need of advice about health, as a means of providing a point of entry to needed medical care. For example, persons who have a regular source of care seem more likely to receive an annual physical examination, to experience continuity of care when needed, and to be satisfied with the care received. Yet, despite the importance of an established tie to a regular treatment source, evidence is scanty with respect to the aged. To address the issue, this study employs data from a national probability sample of 11,619 persons, of whom 1,506 were aged 65 or older. The findings indicate that several factors (e.g., sex, race, education, and community size) which traditionally have served as important indicators of the use of health services fail to emerge as strong determinants regarding the regular source of care among the aged. The consequences of these findings and implications for future research are discussed.

Access to Dental Care

Recent studies have found more equal access to physicians, both in terms of volume of visits and having a regular source. This paper compares physician care with dental care, looking particularly at a regular source of dental care. A regular source should be very important in dental care, given the emphasis on prevention and regular visits. This paper examines data from a statewide sample of 1,329 Rhode Island residents in 1974 to determine what percentage of the population has a regular source and what the relationship is with socioeconomic variables. Most persons (91 per cent) report a regular source of medical care. The figure is somewhat lower (73 per cent) for reporting of a regular source of dental care. Socioeconomic differentials are still important, as only one-half of those in families earning less than $5,000 and 59 per cent of those in families where the head of the household has less than an eighth grade education have a regular source of dental care. The relationship held when controlling for variety of social and demographic variables and partial correlation analysis was used to determine that income, as compared with education, is the more important variable in explaining differentials. Using discriminant function analysis, age, sex, race, education and income allowed one to correctly predict 70.7 per cent of those who have a regular source of dental care and 61.5 per cent of those without a regular source of dental care.

Characteristics of individuals who identify a regular source of medical care.

Having a source where medical services are regularly received is an antecedent to securing high quality medical care; it facilitates access and indicates that the individual is not alienated from the health care delivery system. In this paper we develop models to characterize individuals, both children and adults, who claim a regular source of care. The models are estimated using a logit analysis (since the dependent variable is 0-1) applied to survey data on residents of East Palo Alto, California. These data indicate that in this low-income, predominately black population the most important factor influencing whether a child will have a regular source of medical care is whether the parents have a regular source. For adults, the anticipated need for care (as measured by health status), time in community, and sex were all found to be important. The type of individual least likely to have a regular source of care is a low-income, unmarried male who is in good health and is a recent arrival to the community. The individuals most likely to need easy access to medical care and continuity of care are most likely to have a regular source of care, and vice versa.

Rural access to a regular source of medical care

Household survey data from an adult rural west Texas population were used to investigate the role of demographic, economic, attitudinal, and need-related factors in (a) explaining physician contact and volume of physician visits and (b) differentiating between those individuals who have and those who do not have a regular source of medical care. Fifty-two percent of the variance in visit volume were explained; compared with the findings reported in similar studies, alignment with a regular source of care was more closely associated with visit volume and physician contact. Although the variance explained in having a regular source was only about 18%, the findings suggest that factors determining alignment with a regular source may differ considerably from those determining other dimensions of utilization. Furthermore, patterns evident across several dimensions in rural populations may be quite different from those exhibited in other populations.