the determinants of timely access to quality health care

CHINELO OGBUANU, MD, MPH, PHD, SENIOR MCH EPIDEMIOLOGIST

THE DETERMINANTS OF TIMELY ACCESS TO

QUALITY HEALTH CARE

Presentation to GEORGIA PUBLIC HEALTH ASSOCIATION ANNUAL

MEETINGAPRIL 12TH, 2011

Other Contributors

• Dave Goodman, MS, PhD• Katherine Kahn, MPH• Cherie Long, MPH• Brendan Noggle, MPH• Suparna Bagchi, MS, DrPH• Danielle Barradas, PhD• Brian Castrucci, MA

ACCESS

Access to affordable, quality health

care in our communities

RESPONSIBLE

Responsible health planning

and use of health care resources

HEALTHY

Healthy behaviors and

improved health

outcomes

DCH Mission

FY 2011

DCH InitiativesFY 2011

Continuity of Operations Preparedness

Customer Service

Emergency Preparedness

Financial & Program Integrity

Health Care Consumerism

Health Improvement

Health Care Transformation

Public Health

Workforce Development

Presentation Outline

• Background• Methods• Results• Discussion

Background

• Definitions of Access and Quality• Importance of Access• Associated Factors – Access• Associated Factors – Quality• Prevalence in Georgia• Gaps & Study Question

Definitions of Access & Quality

• Access to care– Timely use of personal health services to achieve the

best possible health outcomes (IOM)

• Quality health care: – Safe, effective, patient-centered, timely, efficient, and

equitable (IOM)– Accessible, family-centered, continuous, comprehensive,

coordinated, compassionate & culturally effective (AAP)

Importance of Access

• Importance of Access– Ensuring the receipt of preventive services– A prerequisite for optimal management of chronic

childhood diseases– Influences children’s physical & emotional growth,

development, overall health and well being

Associated Factors - Access

• Insurance (continuity, type of insurance)• Having a personal health care provider• Having a usual source of care• Race/ethnicity

Associated Factors - Quality

• Race/ethnicity • Insurance• Primary household language• Income• Parental Education

Prevalence in Georgia

• Access to care– Identified as a major health concern for all MCH

populations especially children in Georgia– Based on 2007 NSCH (Georgia children ages 0-17)

• 88.3% had a preventive medical visit in the past year• 58.5% received care within a medical home• Family-centered component of medical home

– HCP spends enough time (79.3%); HCP listens carefully (89.8%)– HCP provides specific needed information (87.8%)– HCP helps parent feel like a partner in care (89.0%)

Gaps & Study Question

• No in-depth exploration of factors associated with access and quality of health care in Georgia

• Study Question: – What are the determinants of access to quality health

care in Georgia among children ages 4-17 years?

Methods

• Study Design• Dependent Variable• Independent Variables – Andersen’s Framework• Data Analysis

Study Design

• Merged dataset:– 2007 NSCH PUF (Interview completion rate: 66%)– Selected 2007 variables from the 2008 Area Resource

File– Medically Underserved Area (MUA) variable for Georgia

• Study Population– Georgia children 4-17 years of age (N = 1,397)

Dependent Variable

• Access to quality health care– Access to care

• Utilization of preventive medical visit in the past year• No occasion of delay or denial of needed care in the past year

– Quality of health care• Health care provider spends enough time with child• Listens carefully to parent• Is sensitive to family values and customs• Provides specific needed information• Makes parent feel like a partner in child’s care

Dependent Variable

• Access to care: Yes/No• Quality of Health Care: Higher/Moderate/Lower• Access to quality health care

– Access to higher quality care– Access to moderate quality care– Access to lower quality care– No access to care

Independent Variables:Andersen’s Theoretical Framework

Data Analysis

• Descriptive Statistics• Bivariable analysis (Chi-square tests)• Significant testing – alpha=0.05• Multivariable Analysis

– Multinomial logistic regression (genlogit approach)– First 2 levels of outcome were collapsed– Access to higher/moderate versus lower quality care– Access to lower quality care versus no access to care

Data Analysis

• Multivariable Analysis– Domain-specific models– Full models (all domains simultaneously)– Ρ-value=0.3 for entry into models and retainership in

final models– Additional analysis on subpopulation of CSHCN (N=319)

• All analysis – SAS-callable SUDAAN 10.0.1

Results

• Descriptive Statistics• Bivariable Results – Associated Factors• Multivariable Results

Descriptive Statistics

• Access to quality health care– Access to higher quality care (32.8%)– Access to moderate quality care (24.8%)– Access to lower quality care (22.8%)– No access to care (19.6%)

Bivariable Results –Associated Factors

• External Domain– Having a recreation center (p=0.03)

• Predisposing Domain– Younger age (4-9 years; p=0.05)– Parental educational level (> HS; p=0.02)– Race/Ethnicity (Being White, NH; p<0.0001)– Non-foreign born child (p=0.03)– English as primary household language (<0.0001)

Bivariable Results – Associated Factors

• Predisposing Domain contd.– Longer stay of mother-type in the US (p=0.0004)– Strongly supportive neighborhood (p<0.0001)

• Enabling Domain– Having continuous & adequate insurance (p<0.0001)– Income > 300% FPL (p=0.0009)– Having a usual source of care (p=0.02)– Having a personal doctor (p=0.01)

Bivariable Results - Associated Factors

• Need Domain– Being in excellent overall health status (p=0.0033)

Multivariable Results

• Detailed results

Discussion

• Summary of Findings• Public Health Implications• Strengths• Limitations

Summary of Findings

• About a third of Georgia children ages 4-17 years had access to higher quality care

• Higher odds of having access to higher/moderate quality care (vs. lower quality care)– Environmental: No presence of vandalism– Predisposing: Being female, living in a strongly supportive

neighborhood– Enabling: Having a usual source of care– Need: CSHCN status, excellent/very good health status

Summary of Findings

• Lower odds of having access to higher/moderate quality care (vs. lower quality care)– Predisposing: Black, NH and Hispanic children– Enabling:

• Children in all other categories of insurance (except ref. group)

• Children living in >100-200%, >200-300%, and above 400% of the FPL

Summary of Findings• Higher odds of having access to lower quality care

– Predisposing: Black, NH & Hispanic children– Enabling:

• Children with continuous-adequate-public insurance• Children living in >200-300% and 400% of the FPL

• CSHCN population– Predisposing: Children ages 4-9yrs (higher odds of having

access to higher/moderate quality care)– Enabling: Children with a usual source of care (higher odds

of having access to lower quality care)

Public Health Implications

• Insurance Coverage– Most mutable factor– Needs to be continuous and adequate– Public programs (Medicaid & Peach Care for Kids)

• Minority race/ethnicity– Cultural differences between providers and patients

Public Health Implications

• CSHCN population– Outreach to older children (10-17) for regular check ups

• May help with transition plans– Training to help pediatricians feel more competent

Strengths

• Composite variable of access and quality• Contextual perspective – ARF & MUA variable• State-level estimates to inform program operations• Well established theoretical framework

Limitations

• Cross-sectional survey• Parent’s perceptions – not verified• Occurrences in the past year• Small numbers – cells had to be collapsed• Lack of multilevel modeling - - future studies

Acknowledgements

• Deb Rosenberg, PhD, University of Illinois, Chicago• Kristin Rankin, PhD, University of Illinois, Chicago• Stephanie Robinson, MPH, Research Data Center• Alex Erhlich, MPH, Research Data Center

Questions?