Racial/ethnic inequities in continuity and site of care: location, location, location.

OBJECTIVE: To examine how continuity of care with the same provider varies by race/ethnicity and by site of care. DATA SOURCES/STUDY SETTING: Secondary data analyses of the 1996-97 Community Tracking Study household survey, a representative cross-sectional sample of 34,858 U.S. adults (aged 18 to 64 years), were employed. STUDY DESIGN: Logistic regression analyses were conducted to explore relationships between respondents' race/ethnicity and having a regular site of care, type of site, and continuity with the same provider at this site. PRINCIPAL FINDINGS: Racial/ethnic minority group members were less likely than whites to identify a regular site of care. Among respondents who identified a regular site, minorities, particularly Spanish-speaking Hispanics, reported less continuity of care with the same provider. However, these disparities in continuity were largely explained by racial/ethnic differences in the types of places where care was obtained. Compared to those who were seen in physicians' offices, continuity with the same provider was much lower among respondents who were seen in hospital out patient departments or health centers or other clinics. CONCLUSIONS: Racial and ethnic minority group members receive less continuity of care for reasons including lack of a regular site of care and less continuity with the same provider. Greater use of hospital clinics and community health centers by minorities also contributes to this discontinuity.

Racial and ethnic disparities in perceptions of physician style and trust.

CONTEXT: While pervasive racial and ethnic inequalities in access to care and health status have been documented, potential underlying causes, such as patients' perceptions of their physicians, have not been explored as thoroughly. OBJECTIVE: To assess whether a person's race or ethnicity is associated with low trust in the physician. DESIGN, SETTING, AND PARTICIPANTS: Data were obtained from the 1996 through 1997 Community Tracking Survey, a nationally representative sample. Adults who identified a physician as their regular provider and had at least 1 physician visit in the preceding 12 months were included (N = 32,929). MAIN OUTCOME MEASURE: Patients' ratings of their satisfaction with the style of their physician and their trust in physicians. The Satisfaction With Physician Style Scale measured respondents' perceptions of their physicians' listening skills, explanations, and thoroughness. The Trust in Physician Scale measured respondents' perceptions that their physicians placed the patients' needs above other considerations, referred the patient when needed, performed unnecessary tests or procedures, and were influenced by insurance rules. RESULTS: After adjustment for socioeconomic and other factors, minority group members reported less positive perceptions of physicians than whites on these 2 conceptually distinct scales. Minority group members who lacked physician continuity on repeat clinic visits reported even less positive perceptions of their physicians on these 2 scales than whites. CONCLUSIONS: Patients from racial and ethnic minority groups have less positive perceptions of their physicians on at least 2 important dimensions. The reasons for these differences should be explored and addressed. Arch Fam Med. 2000;9:1156-1163

The distribution of rural female generalist physicians in the United States.

Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women in medicine have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States. We examine the geographic distribution of all active U.S. allopathic physicians recorded in the October 1996 update of the American Medical Association Physician Masterfile. Percentages and numbers of female physicians by professional activity, specialty type, and geographic location are reported. Findings reveal there were fewer than 7,000 female allopathic physicians practicing in rural America in 1996. The proportion of generalist female physicians who practice in rural settings was significantly lower than the proportion who practice in urban locations. Although members of the most recent 10-year medical school graduation cohort of female generalist physicians were slightly more likely to practice in rural areas than members of earlier cohorts, female physicians remained significantly underrepresented in rural areas. States varied dramatically in rural female generalist underrepresentation. Should female generalists continue to be underrepresented in rural locations, the rural physician shortage will not be resolved quickly. Effective strategies to improve rural female physician placement and retention need to be identified and implemented to improve rural access to physician care.

Physicians' advice to quit smoking. The glass remains half empty.

BACKGROUND: We explored the relationships between advice from a physician to quit smoking and an array of respondents' characteristics, including sociodemographic factors, health status, health insurance status, physician continuity, and intensity of smoking. METHODS: We examined data from the nationally representative 1996-1997 Community Tracking Study Household Survey. We used multivariate logistic regression to model receipt of cessation advice in a sample of 8229 smokers aged 18 years and older who made at least one visit to a physician in the past year. RESULTS: Less than 50% of the subjects reported receiving cessation advice. Advice was less likely for patients who were younger, men, African American, uninsured, healthier, lower health care services users, or lighter smokers, and more likely for those with military health insurance, who attended hospital outpatient clinics, or who belonged to health maintenance organizations. CONCLUSIONS: Physicians continue to miss opportunities to provide smoking cessation advice, a potentially lifesaving intervention. Given the adverse health consequences of tobacco use and the demonstrated benefit of advice to quit, physicians need to improve their cessation counseling efforts.

US medical schools and the rural family physician gender gap.

BACKGROUND: Women comprise increasing proportions of medical school graduates. They tend to choose primary care but are less likely than men to choose rural practice. METHODS: This study used American Medical Association masterfile data on 1988-1996 medical school graduates to identify the US medical schools most successful at producing rural family physicians and general practitioners of both genders. RESULTS: The number of listed rural female family physician or general practitioner graduates among schools ranged from 0-27 (0% to 4.4% of each school's 1988-1996 graduates). There were approximately twice as many male as female rural family physicians and general practitioners. Publicly funded schools produced more rural female family physicians and general practitioners than their privately funded counterparts. CONCLUSIONS: Our findings suggest that a few schools, most of them public, may serve as models for schools that aim to train women who later enter rural practice.

Supplemental insurance and mortality in elderly Americans. Findings from a national cohort.

CONTEXT: As the burden of out-of-pocket health care expenditures for Medicare beneficiaries has grown, the need to assess the relationship between uncovered costs and health outcomes has become more pressing. OBJECTIVE: To assess the relationship between risk for out-of-pocket expenditures and mortality in elderly persons with private supplemental insurance. DESIGN: Retrospective cohort study using proportional hazards survival analyses to assess mortality as a function of health insurance, adjusting for sociodemographic, access, and case mix-health status measures. SETTING: The 1987 National Medical Expenditure Survey, a representative cohort of the US civilian population, linked to the National Death Index. PARTICIPANTS: A total of 3751 persons aged 65 years and older. MAIN OUTCOMES MEASURES: Five-year mortality rate. RESULTS: After 5 years, 18.5% of persons at low risk for out-of-pocket expenditures, 22.5% of those at intermediate risk, and 22.6% of those at high risk had died. After multivariate adjustment, a significant linear trend (P = .02) toward increasing mortality with increasing risk category was observed. Compared with the low-risk group, persons in the intermediate-risk group had an adjusted hazard ratio of 1.2 (95% confidence interval, 0.9-1.6), whereas those in the high-risk group had an adjusted hazard ratio of 1.4 (95% confidence interval, 1.0-1.9). CONCLUSIONS: Increasing risk for out-of-pocket costs is associated with higher subsequent mortality among elderly Americans with supplemental private coverage. Although research is needed to identify which specific components of out-of-pocket expenditures are adversely associated with health outcomes, findings support policies to decrease out-of-pocket health care expenditures to reduce the risk for premature mortality in elderly Americans.

To buy, or not to buy: factors associated with the purchase of nongroup, private health insurance.

BACKGROUND: Employment-based health insurance coverage is declining in the United States. Many recent efforts to increase coverage have promoted the individual purchase of insurance, with or without subsidies. OBJECTIVES: To study the associations of factors including minority group membership, education, income, wealth, and health status with the voluntary purchase of nongroup, private health insurance. DESIGN: Analysis of the 1987 National Medical Expenditure Survey (NMES). SUBJECTS: Adult respondents to the NMES who were younger than 65 years of age in 2,574 health-insurance eligibility units (HIEUs) and who either were uninsured or who purchased nongroup, private health insurance for all of 1987. MEASURES: Adjusted odds ratios and marginal effects for the associations of minority group membership, educational attainment, income, and wealth with the purchase of nongroup insurance. RESULTS: Lower-income and less-wealthy HIEUs were much less likely to purchase insurance than higher-income and wealthier HIEUs, with income and wealth measures having relatively independent effects. With simultaneous adjustment for income, wealth, and other factors, members of minority groups had less than half the odds of non-Hispanic whites and persons with less than a high school education had less than half the odds of college graduates of purchasing nongroup insurance. CONCLUSIONS: Minorities and the less educated are much less likely to buy their own health insurance, even after adjustment for income and wealth. Programs encouraging the voluntary purchase of health insurance are likely to widen coverage gaps between historically disadvantaged groups and others.

Is family care associated with reduced health care expenditures?

BACKGROUND: Specific components of family medicine associated with reduced health care costs are not well understood. We examined whether people who received "family care," the sharing of a personal physician across familial generations, had lower health care expenditures than those who received "individual care" that lacked generational continuity. METHODS: We studied 1728 children and 2543 adults using a data subset of the 1987 National Medical Expenditure Survey, a representative sample of the civilian noninstitutionalized US population, to examine the relationship between care category and total health care expenditures, adjusting for potential confounders and effect modifiers. Survey respondents from households with either a married or a single woman aged 18 to 55 years as head of household and at least 1 child younger than 18 years were included. Only individuals reporting a family physician (FP) or general practitioner (GP) as their personal doctor were examined, since intergenerational family care is provided almost exclusively by FPs and GPs. RESULTS: Family care provided by an FP or GP was associated with 14% lower expenditures for adults ($51), after adjustment for covariates (P = .04), compared with individual care provided by a family or general practitioner. Although not statistically significant, for children family care was associated with 9% lower expenditures ($19). CONCLUSIONS: These findings suggest that family care provided by FPs or GPs is associated with lower health care costs. Policies promoting family care may reduce health care costs.

Does skepticism towards medical care predict mortality?

OBJECTIVES: Attitudes towards medical care have a strong effect on utilization and outcomes. However, there has been little attention to the impact on outcomes of doubts about the value of medical care. This study examines the impact of skepticism toward medical care on mortality using data from the 1987 National Medical Expenditure Survey (NMES). METHODS: A nationally representative sample from the United States comprising 18,240 persons (> or = 25 years) were surveyed. Skepticism was measured through an 8-item scale. Mortality at 5-year follow-up was ascertained through the National Death Index. RESULTS: In a proportional hazards survival analysis of 5-year mortality that controlled for age, sex, race, education, income, marital status, morbidity, and health status, skepticism toward medical care independently predicted subsequent mortality. That risk was attenuated after adjustment for health behaviors but not after adjustment for health insurance status. CONCLUSION: Medical skepticism may be a risk factor for early death. That effect may be mediated through higher rates of unhealthy behavior among the medically skeptical. Further studies using more reliable measures are needed.

Family care in the United States. A national profile.

OBJECTIVES: The authors describe the epidemiology of family care in the United States. METHODS: A cross-sectional analysis of data from the household component of the 1987 National Medical Expenditure Survey was performed. A representative sample of the civilian, noninstitutionalized US population was analyzed. Participants in the study were all households with at least a mother between the ages of 18 and 55 years and at least one child younger than age 18 (n = 2,975). For this analysis, family care was defined as all families in which there was provider congruence between at least one parent and one child, compared with individual care, defined as families with separate providers. RESULTS: Family care occurred in 35% of families studied. As opposed to individual care, family care was more prevalent in families that resided in non-standard metropolitan statistical area regions and outside of the Northeast, as well as in families whose female heads of household were less educated, older, and had higher unhealthy behavior scores. Except for unhealthy behavior scores, these results remained significant after multivariate adjustment for race, marital status, family income, insurance status, and health care attitudes. Family or general practitioners were more likely than other physicians to provide family care. CONCLUSIONS: Family care occurs in a significant proportion of US families, and location and education are significant determinants of this kind of care. This descriptive epidemiologic analysis of a nationally representative sample provides a foundation for studies examining the cost and quality implications of family care.