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ABSTRACT: Objectives: To examine health care access disparities with regard to health status and presence of functional limitations, a common measure of disability and multimorbidity, after controlling for individual's race/ethnicity, insurance status and income in the U.S. using the latest survey data. METHODS: Using data from the 2009 Family Core component of the National Health Interview Survey (NHIS), we examined six measures of access to care in the twelve months prior to the interview. Covariates included self-perceived health status and the presence of functional limitations, race/ethnicity, insurance status, income, and other socioeconomic characteristics. Multiple logistic regressions were used to examine the associations. RESULTS: People with functional limitations or worse health status experience greater barriers to access. Insurance status was the single factor that was associated with all six measures of access. Disparities among racial/ethnic groups in most access indicators as well as income levels were insignificant after taking into account individuals' health status measures. CONCLUSIONS: Interventions to expand insurance coverage and the Patient Protection and Affordable Care Act are expected to contribute to reducing disparities in access to care. However, to further improve access to care, emphasis must be placed on those with poorer health status and functional limitations.
International Journal for Equity in Health 05/2013; 12(1):29. · 1.71 Impact Factor
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ABSTRACT: OBJECTIVES: This study provides a snapshot of the current state of primary care workforce (PCW) serving China's grassroots communities and examines the factors associated with their job satisfaction. METHODS: Data for the study were from the 2011 China Primary Care Workforce Survey, a nationally representative survey that provides the most current assessment of community-based PCW. Outcome measures included 12 items on job satisfaction. Covariates included intrinsic and extrinsic factors associated with job satisfaction. In addition, PCW type (ie, physicians, nurses, public health, and village doctors) and practice setting (ie, rural versus urban) were included to identify potential differences due to the type of PCW and practice settings. RESULTS: The overall satisfaction level is rather low with only 47.6% of the Chinese PCW reporting either satisfied or very satisfied with their job. PCW are least satisfied with their income level (only 8.6% are either satisfied or very satisfied), benefits (12.8%), and professional development (19.5%). They (particularly village doctors) are also dissatisfied with their workload (37.2%). Lower income and higher workload are the two major contributing factors toward job dissatisfaction. Conclusion To improve the general satisfaction level, policymakers must provide better pay and benefits and more opportunities for career development, particularly for village doctors.
Primary Health Care Research & Development 02/2013;
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ABSTRACT: Objectives. We examined utilization, unmet need, and satisfaction with oral health services among Federally Qualified Health Center patients. We examined correlates of unmet need to guide efforts to increase access to oral health services among underserved populations. Methods. Using the 2009 Health Center Patient Survey, we performed multivariate logistic regressions to examine factors associated with access to dental care at health centers, unmet need, and patient experience. Results. We found no racial or ethnic disparities in access to timely oral health care among health center patients; however, uninsured patients and those whose insurance does not provide dental coverage experienced restricted access and greater unmet need. Slightly more than half of health center patients had a dental visit in the past year, but 1 in 7 reported that their most recent visit was at least 5 years ago. Among health center patients who accessed dental care at their health center, satisfaction was high. Conclusions. These results underscore the critical role that health centers play in national efforts to improve oral health status and eliminate disparities in access to timely and appropriate dental services. (Am J Public Health. Published online ahead of print January 17, 2013: e1-e6. doi:10.2105/AJPH.2012.300846).
American Journal of Public Health 01/2013; · 3.93 Impact Factor
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ABSTRACT: More than 1100 federally funded health centers provide primary and preventive care to about 20 million underserved patients in the United States. Since 2008, the Health Resources and Services Administration has implemented a clinical quality improvement initiative to measure and evaluate the quality of care across all health centers. We assessed racial/ethnic disparities in clinical quality among US health centers, and examined whether performance on quality measures varied across 3 health center characteristics. National data came from the 2009 Uniform Data System. We examined performance across 3 indicators of clinical quality: poorly controlled hypertension among adult patients, poorly controlled diabetes among adult patients, and low birth weight among newborns. We compared results for each measure across racial/ethnic groups, as well as across 3 health center characteristics: health center patient volume, duration of health center funding, and extent of managed care penetration. Non-Hispanic Asian patients had the best results among racial/ethnic groups for 2 of the 3 measures examined: lowest rates of poorly controlled diabetes (26%) and hypertension (34%). Hispanics/Latinos had similar rates of poor hypertension control compared with non-Hispanic whites (38% for both), and lower rates of low birth weight (8% vs 10%). Poor diabetes control was more prevalent among Hispanic/Latino patients than non-Hispanic white patients, but the absolute difference was small (5 percentage points). Non-Hispanic black/African American patients had statistically worse outcomes than non-Hispanic white patients, but the absolute differences were also small (2-6 percentage points, depending on outcome). Health centers with larger patient volume fared better than their counterparts with smaller volume for all racial/ethnic groups. For Hispanic/Latino patients, more established health centers compared favorably to new health centers for all 3 outcomes. Health centers with some managed care penetration did better for diabetes and hypertension control relative to health centers without managed care penetration. Compared with national rates, health centers report minimal racial/ethnic disparities in clinical outcomes. Health center characteristics are also associated with clinical outcomes. More research is needed to determine the nature of disparities after accounting for health center patient, provider, and institutional characteristics.
The Journal of ambulatory care management 01/2013; 36(1):24-34.
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ABSTRACT: China passed a landmark health care reform in 2009, aimed at improving health care for all citizens by strengthening the primary care system, largely through improvements to infrastructure. However, research has shown that the work attitudes of primary care physicians (PCPs) can greatly affect the stability of the overall workforce and the quality and delivery of health care. The purpose of this study is to investigate the relationship between reported work attitudes of PCPs and their personal, work, and educational characteristics. A multi-stage, complex sampling design was employed to select a sample of 434 PCPs practicing in urban and rural primary care settings, and a survey questionnaire was administered by researchers with sponsorship from the Ministry of Health. Four outcome measures describing work attitudes were used, as well as a number of personal-, work-, and practice-related factors. Findings showed that although most PCPs considered their work as important, a substantial number also reported large workloads, job pressure, and turnover intentions. Findings suggest that policymakers should focus on training and educational opportunities for PCPs and consider ways to ease workload pressures and improve salaries. These policy improvements must accompany reform efforts that are already underway before positive changes in reduced disparities and improved health outcomes can be realized in China.
International Journal of Health Services 01/2013; 43(1):167-81. · 1.21 Impact Factor
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ABSTRACT: This paper examined disparities in access to and satisfaction with primary care among patients of different racial/ethnic groups and insurance coverage, in health centers and the nation overall. Data came from the 2009 Health Center Patient Survey and 2009 Medical Expenditure Panel Survey. Study outcomes included usual source of care, type of usual source of care, satisfaction with provider office hours, and satisfaction with overall care. Health center patients were more racially and ethnically diverse than national patients, and health center patients were more likely than national patients to be uninsured or publicly insured. No significant health care disparities in access to care existed among patients from different racial/ethnic and insurance groups among health centers, unlike low-income patients nationwide or the U.S. population in general. Additional focus on the uninsured, in health centers and other health care settings nationwide, is needed to enhance satisfaction with care among these patients.
Journal of Health Care for the Poor and Underserved 01/2013; 24(1):56-66. · 1.10 Impact Factor
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Lydie A Lebrun, Leiyu Shi,
Joya Chowdhury,
Alek Sripipatana,
Jinsheng Zhu,
Ravi Sharma,
A Seiji Hayashi,
Charles A Daly,
Naomi Tomoyasu,
Suma Nair,
Quyen Ngo-Metzger
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ABSTRACT: The goal of the current study was to examine primary care and public health activities among federally funded health centers, to better understand their successes, barriers encountered, and lessons learned.
Qualitative and quantitative methods were used to collect data from nine health centers, stratified by administrative division, urban-rural location, and race/ethnicity of patients served. Descriptive data on patient and institutional characteristics came from the Uniform Data System, which collects data from all health centers annually. Questionnaires were administered and phone interviews were conducted with key informants.
Health centers performed well on primary care coordination and community orientation scales and reported conducting many essential public health activities. Specific needs were identified for integrating primary care and public health: (1) more funding for collaborations and for addressing the social determinants of health, (2) strong leadership to champion collaborations, (3) trust-building among partners, with shared missions and clear expectations of responsibilities, and (4) alignment and standardization of data collection, analysis, and exchange.
Lessons learned from health centers should inform strategies to better integrate public health with primary care.
American journal of preventive medicine 06/2012; 42(6 Suppl 2):S191-202. · 4.24 Impact Factor
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Lydie A Lebrun, Leiyu Shi,
Joya Chowdhury,
Alek Sripipatana,
Jinsheng Zhu,
Ravi Sharma,
A Seiji Hayashi,
Charles A Daly,
Naomi Tomoyasu,
Suma Nair,
Quyen Ngo-Metzger
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ABSTRACT: We examined primary care and public health activities among federally funded health centers, to better understand their successes, the barriers encountered, and the lessons learned.
We used qualitative and quantitative methods to collect data from 9 health centers, stratified by administrative division, urban-rural location, and race/ethnicity of patients served. Descriptive data on patient and institutional characteristics came from the Uniform Data System, which collects data from all health centers annually. We administered questionnaires and conducted phone interviews with key informants.
Health centers performed well on primary care coordination and community orientation scales and reported conducting many essential public health activities. We identified specific needs for integrating primary care and public health: (1) more funding for collaborations and for addressing the social determinants of health, (2) strong leadership to champion collaborations, (3) trust building among partners, with shared missions and clear expectations of responsibilities, and (4) alignment and standardization of data collection, analysis, and exchange.
Lessons learned from health centers should inform strategies to better integrate public health with primary care.
American Journal of Public Health 06/2012; 102 Suppl 3:S383-91. · 3.93 Impact Factor
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ABSTRACT: OBJECTIVE: To describe current clinical quality among the nation's community health centers and to examine health center characteristics associated with performance excellence. DATA SOURCES: National data from the 2009 Uniform Data System. DATA COLLECTION/EXTRACTION METHODS: Health centers reviewed patient records and reported aggregate data to the Uniform Data System. STUDY DESIGN: Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance. PRINCIPAL FINDINGS: Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well. CONCLUSIONS: Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.
Health Services Research 05/2012; · 2.16 Impact Factor
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ABSTRACT: China is a country with vast regional differences and uneven economic development, which have led to widening gaps between the rich and poor in terms of access to healthcare, quality of care, and health outcomes. China's healthcare reform efforts must be tailored to the needs and resources of each region and community. Building and strengthening primary care within the Chinese health care system is one way to effectively address health challenges. This paper begins by outlining the concept of primary care, including key definitions and measurements. Next, results from a number of studies will demonstrate that primary care characteristics are associated with savings in medical costs, improvements in health outcomes and reductions in health disparities. This paper concludes with recommendations for China on successfully incorporating a primary care model into its national health policy, including bolstering the primary care workforce, addressing medical financing structures, recognizing the importance of evidence-based medicine, and looking to case studies from countries that have successfully implemented health reform.
International Journal for Equity in Health 01/2012; 11:2. · 1.71 Impact Factor
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ABSTRACT: We compared patient management during primary care visits in 3 settings (health centers, hospital outpatient departments, and physicians' offices) and investigated racial/ethnic and insurance-based disparities in the wake of the recent health center program expansion. Within health centers, there were few differences in patient management across racial/ethnic or insurance groups. In contrast, the other settings displayed more racial/ethnic and insurance disparities in patient management during visits. Health centers performed processes of care with comparable or higher occurrence, relative to physicians' offices. Health care disparities were also attenuated in health centers, compared with other primary care settings.
The Journal of ambulatory care management 01/2012; 35(1):60-74.
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ABSTRACT: Large health disparities exist in the U.S. across ethnic and socioeconomic status groups. Using nationally representative data, we tested whether American patients with diet-related chronic diseases had higher diet quality than nonpatients. We also tested whether nutrition knowledge and beliefs (NKB) and food label (FL) use were associated with the observed differences. The 1994-1996 Continuing Survey of Food Intake by Individuals, and the Diet and Health Knowledge Survey were examined for 4356 U.S. adults. Dietary intakes were assessed using 2 nonconsecutive 24-h recalls and diet quality was assessed by using the USDA 2005 Healthy Eating Index (HEI). Patients' mean HEI was higher than that of nonpatients (mean ± SE: 53.6 ± 0.5 vs. 51.8 ± 0.4; P < 0.001). Among patients, blacks were 92% more likely to report low diet quality (HEI < 20th percentile) than whites. The positive association between chronic diseases and HEI was observed only for patients with good NKB [OR = 1.80 (95% CI = 1.34, 2.43)]. The diabetes-HEI association was stronger among FL users [OR = 2.24 (95% CI = 1.08, 4.63)] than non-FL users [OR = 1.33 (95% CI = 0.65, 2.73)]. Hypertensive patients' and nonpatients' diet quality did not significantly differ; linear regression models showed no difference in their HEI (β ± SE: 0.6 ± 0.6; P > 0.05) or sodium intake (-18.6 ± 91.4 g/d; P > 0.05) between them. In conclusion, U.S. adults with diet-related chronic diseases reported somewhat higher diet quality than nonpatients, especially among those patients with good NKB and use of FL. Efforts are needed to promote healthy eating among Americans with diet-related chronic diseases; nutrition education and promotion of FL use may help.
Journal of Nutrition 06/2011; 141(8):1543-51. · 3.92 Impact Factor
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ABSTRACT: 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.
Journal of Health Care for the Poor and Underserved 01/2011; 22(3):945-61. · 1.10 Impact Factor
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ABSTRACT: We conducted cross-country comparisons of Canada and the U.S., and assessed the extent to which access to care varies by nativity status overall, as well as in conjunction with race/ethnicity and socioeconomic status. Data came from the Joint Canada-U.S. Survey of Health (n=6,620 non-elderly adults). Access measures included having a regular medical doctor, consultation with a health professional in the past year, dentist visit in the past year, Pap test in the past three years, and any unmet health care needs in the past year. Logistic regression was employed to estimate the relative odds of access to care, adjusting for potential confounders. Disparities in access to care based on nativity status overall, as well as nativity-by-race joint effects, were found in both countries. There was also a dose-response effect of education on access to care among the native-born but not among the foreign-born; there were few nativity-by-income joint effects.
Journal of Health Care for the Poor and Underserved 01/2011; 22(3):1075-100. · 1.10 Impact Factor
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ABSTRACT: The overall aim was to determine whether health care delivery for vulnerable populations served by community health centers (CHCs) was comparable to care for mainstream Americans primarily seen in physicians' offices (POs). Data came from the 2006 National Ambulatory Medical Care Survey. Patient visits occurring in CHCs were largely from younger, uninsured or Medicaid-insured, minority populations, while POs catered mainly to older, Medicare- or privately-insured, White patients. Communities served by CHCs were more often in low-income, low-education, urban regions. A greater proportion of visits to CHCs were from diabetic, obese, and depressed patients; CHCs also offered more evening/weekend visits and provided more health education during visits, but spent less time per visit than POs and had more difficulty referring patients to specialists. Results affirmed the significant role of CHCs as safety-net providers for vulnerable populations, and indicated that CHCs provide adequate care compared with POs although there remains room for improvement.
Journal of Health Care for the Poor and Underserved 11/2010; 21(4):1169-83. · 1.10 Impact Factor
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ABSTRACT: This study used a recent patient survey to examine the relationship between having a usual source of care (USC) and the quality of ambulatory medical care experiences in Taiwan, where there is universal health insurance coverage. RESEARCH DESIGN, SUBJECTS, AND MEASURES: The study design was a cross-sectional survey of 879 patients in Taichung County, Taiwan. Children and adults visiting hospital-based physicians were included. Quality of care was measured using items from the Primary Care Assessment Tool (PCAT), representing 7 ambulatory medical care domains: first contact (ie, access 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. USC was defined based on responses to 3 survey items from the PCAT.
Having a USC was significantly associated with higher quality of medical care experiences. Specifically, having a USC was associated with improved accessibility and utilization, ongoing care, coordination of referrals, and healthcare providers' family centeredness and cultural competence. However, having a USC was not strongly related with comprehensiveness of services, coordination of information systems, or healthcare providers' community orientation.
In a region with universal health insurance, patients with a USC reported higher quality of medical care experiences compared with those without a USC. Beyond the provision of health insurance coverage, efforts to improve quality of care should include policies promoting USC.
Medical care 07/2010; 48(7):628-34. · 3.24 Impact Factor
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ABSTRACT: After accounting for socioeconomic factors and other demographic characteristics, racial/ethnic disparities in access to care were examined.
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.
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.
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.
Southern medical journal 06/2010; 103(6):509-16. · 0.92 Impact Factor
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ABSTRACT: 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.
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.
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.
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.
Ethnicity and Health 12/2009; 14(6):625-42. · 1.64 Impact Factor
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ABSTRACT: 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.
Journal of public health management and practice: JPHMP 11/2008; 14 Suppl:S45-52. · 0.96 Impact Factor
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ABSTRACT: The authors examined changes in medical care experiences of racial/ethnic groups (non-Hispanic white, Asian and Pacific Islander, Hispanic, and non-Hispanic black) between 1996 and 2002, using data from the Household Component of Medical Expenditure Panel Surveys. Proportions and adjusted odds ratios for each group's primary care experience are presented. Comparisons are made between groups at each time period and within groups between the two time periods. Multivariable analyses control for demographic and socioeconomic characteristics, health care needs and source of care, and health insurance. Racial/ethnic minorities experienced worse medical care than non-Hispanic whites, but results differed among groups. Non-Hispanic blacks were no different from non-Hispanic whites and showed a slight improvement over time, except for lower odds of having a usual source of care and worse sociodemographic and health indicators. Hispanics had worse experiences than whites in 5 of 8 indicators in 2002 (vs. 3 in 1996). Asians assessed their experience as worse than that of whites in 6 of 8 indicators in 2002 (vs. 3 in 1996), yet had higher self-rated health and education than non-Hispanic whites. Disparities in medical care experience have increased for some groups, and efforts must be made to reduce financial and nonfinancial barriers to care for racial/ethnic minority populations.
International Journal of Health Services 02/2008; 38(4):653-70. · 1.21 Impact Factor
