Access to Health Care in America (1993) / Chapter Skim
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3. Using Indicators to Monitor National Objectives for Health Care
3. Using Indicators to Monitor National Objectives for Health Care
Pages 46-129
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From page 46... ...
Implicit in the committee's definition of access is the idea that certain services improve health. Thus, for many, if not most, personal health care services, there is an expectation of benefit, and that benefit extends beyond such obviously important outcomes as avoiding death to more subtle quality-oflife values like physical and social functioning.
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From page 48... ...
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From page 49... ...
Women at high risk for poor pregnancy outcomes- such as those who smoke, those who suffer from malnutrition or nutritional imbalance, or those who are addicted to drugs or alcohol may need to take part in a wide range of medical, health education, and social service programs. The content of prenatal care can vary widely depending on the patient's needs, what health care services are available, and which of the available services the patient chooses to take advantage of.
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From page 50... ...
There is considerable evidence that WIC participation reduces rates of low birthweight and infant mortality (Caan et al., 1987; Centers for Disease Control, 1978; Colt, 1977; Collins et al., 1985; Food Research Action Center, 1991; Kennedy and Kotelchuck, 1984; Rush et al., 1988b; Schramm, 1986~. Other research (Kotelchuck et al., 1984; Rush et al., 1988a; U.S.
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From page 51... ...
However, securing direct evidence of the link between income and access to care on a routine basis is difficult since income information is not reported on birth certificates. The Health Resources and Services Administration is testing the feasibility of combining the information provided on birth certificates with income data by zip code from the Census Bureau to estimate the income levels of women who use varying quantities of prenatal care services.
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From page 52... ...
For all races, slightly less than 70 percent of all women received adequate prenatal care in each of the three years. In each year nearly three-quarters of white women but only one-half of black women received adequate care.
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From page 53... ...
, 1986-1988 Care Level All Races Black White Adequate 1986 68.4 50.6 72.6 1987 68.7 50.7 73.2 1988 68.9 50.7 73.5 Intermediate 1986 23.6 34.2 21.0 1987 23.2 33.6 20.6 1988 23.1 33.8 20.4 Inadequate 1986 8.0 15.3 6.3 1987 8.1 15.7 6.2 1988 8.0 15.5 6.1 SOURCE: National Center for Health Statistics, based on data from 49 reporting states and the District of Columbia. 53 mother, seeking early prenatal care.
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From page 54... ...
Data from 1982 and 1983, collected during cycle III of the National Survey of Family Growth, show that 80 percent of white women who began prenatal care during the first trimester visited a personal, private physician (as opposed to a hospital, health department, or clinic) , whereas only 48 percent of black women receiving early prenatal care did so (National Center for Health Statistics, 1988~.
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From page 55... ...
In addition, a longitudinal follow-up study was begun in 1990. The study will provide more information on the dynamics of prenatal care; child development; and the effects of low birthweight, child nutrition, and exposure to environmental hazards.
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From page 56... ...
Efforts should be made to develop an index that measures the timing, sensitivity, content, and quality of prenatal care and that accounts for the effects of various risk factors in determining adequacy. Outcome Indicator: Infant Mortality Infant mortality refers to children who die before their first birthday.
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From page 57... ...
Unfortunately, most of the routinely available data on infant mortality do not provide information about access barriers, which inhibits our ability to better understand the relationship between financial, structural, and personal barriers and outcomes. To analyze factors that contribute to infant mortality, death certificates frequently are "linked" to birth records, which contain information about the mother's use of prenatal care services and other factors that influence the outcome of pregnancy.
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From page 58... ...
N.a. Neonatal Mortality RatesC 1970 15.1 13.8 21.4 22.8 1.65 1975 11.6 10.4 16.8 18.3 1.76 1980 8.5 7.5 12.5 14.1 1.88 1981 8.0 7.1 11.8 13.4 1.89 1982 7.7 6.8 11.3 13.1 1.93 1983 7.3 6.4 10.8 12.4 1.94 1984 7.0 6.2 10.2 11.8 1.90 1985 7.0 6.1 10.3 12.1 1.98 1986 6.7 5.8 10.1 11.7 2.02 1987 6.5 5.5 10.0 11.7 2.13 1988 6.3 5.4 9.7 11.5 2.13 1989 6.3b N.a.
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From page 59... ...
As Table 3-5 shows, infant mortality rates for blacks are much higher than for whites. The absolute differences in rates between the races have narrowed, from approximately 15 more black deaths per 1,000 live births in 1970 to approximately 9 more deaths in 1988; however, the ratio of black to white infant deaths has increased substantially.
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From page 60... ...
have infant mortality rates that are well above the national averages. For Puerto Ricans, higher infant mortality rates are a result of both high neonatal and postneonatal mortality rates.
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From page 61... ...
Births of low-birthweight and very-low-birthweight infants frequently are associated with inadequate prenatal care and lack of access to nutrition services. Unlike infant mortality (which may be influenced both by the health care services received by the mother during pregnancy and the care received by the infant up to one year after delivery)
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From page 62... ...
provides more detailed information about the extent of prenatal care and risk factors associated with low birthweight and very low birthweight. Additional understanding of the low-birthweight problem should be possible when 1989 birth certificate data become available for analysis.
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From page 63... ...
. The DHHS's Health Objectives for the Year 2000 set a goal of reducing the incidence of low birthweight to 5 per 1,000 live births, the same rate proposed in the department's health plan for 1990 (U.S.
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From page 64... ...
A significant amount of research attention has focused on whether the disparity in the rates of low birthweight between whites and blacks can be explained solely by differences in access barriers and maternal risk factors. The manner in which birthweight data have been analyzed seems to indicate that low birthweight is significantly related to race.
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From page 65... ...
The committee believes that the effects on low birthweight of insurance status and income need to be examined in greater detail. Analyses that use data from the NMIHS or, if available, comparisons of selected states that have linked Medicaid and birth certificate data could provide useful information about the impact of insurance coverage.
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From page 66... ...
A 1990 editorial in the American Journal of Public Health had this comment: Congenital syphilis should be a disease of the past. It is fully preventable by treating infected women with penicillin early in pregnancy, provided that infection or reinfection late in pregnancy does not occur.
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From page 67... ...
and congenital syphilis for selected years from 1970 through 1990. Information on both primary and secondary syphilis is included because the incidence of congenital syphilis closely mirrors the rate of primary and secondary infection in women and because treatment of infected women is the only way to prevent congenital syphilis.
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From page 68... ...
SOURCES: National Center for Health Statistics (1990c) ; Centers for Disease Control data.
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From page 69... ...
The committee also believes that research should be conducted to examine the relationships among drug use, sexually transmitted diseases, and the use of prenatal care services. Such research may shed light on ways of making prenatal care and substance abuse treatment more accessible to this extremely high-risk population and lead to better measures of structural barriers to access.
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From page 70... ...
For school-age children, vaccination is required by law in most jurisdictions, but it is generally not required for younger children. Low rates of immunization may indicate the presence of important barriers to other preventive health care services as well.
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From page 71... ...
USING INDICATORS TO MONITOR NATIONAL OBJECTIVES TABLE 3-10 Recommended Immunization Schedule for Children Age Vaccines 2 Months . 4 Months ...DPTa (first)
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From page 72... ...
72 ACCESS TO HEALTH CARE IN AMERICA TABLE 3-11 Vaccinations of Children 1= Years of Age (as percentage of population) for Selected Diseases, by Race and Residence in Metropolitan Statistical Area (MSA)
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From page 73... ...
One month prior to the interview, all sampled households were asked to check vaccination records, such as those from a private physician, health department, or military. SOURCE: Unpublished data from the U.S.
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From page 74... ...
Medicaid covers immunizations, either on its own or through its Early Periodic Screening, Diagnosis, and Treatment program; some but not all private insurers offer this coverage. These findings thus show the importance of health insurance coverage for specific services.
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From page 75... ...
Absent a system for monitoring the immunization status of the entire U.S. population, the incidence of vaccine-preventable diseases is a good indicator of access problems related to vaccination, a key preventive health service.
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From page 76... ...
76 ACCESS TO HEALTH CARE IN AMERICA problem; rather, the disease's magnitude must be interpreted in relation to its natural history. This makes year-to-year comparisons of the number of cases of a particular disease problematic, because a small number of cases in one year may mask a problem with immunization rates.
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From page 77... ...
77 o o ~ o ca o o o · U
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From page 78... ...
The reporting of information about insurance status, family income, and other barriers to access also is incomplete. Moreover, if it is true, as some believe, that private physicians are increasingly reluctant to give immunizations, the site of immunization will be an additional important clue to the barriers that may need to be overcome.
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From page 79... ...
Measuring the Indicator The measure of utilization of breast cancer and cervical cancer screening tests is the percentage of women in specific age groups who undergo the procedures during a given time period. Two of the primary sources of data for monitoring the use of cancer screening services are the National Health Interview Survey (NHIS)
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From page 80... ...
59.3 15.8 7.8 17.0 SOURCE: Unpublished data from the National Health Interview Survey, National Center for Health Statistics, 1987.
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From page 81... ...
24.3 7.6 7.0 61.1 SOURCE: Unpublished data from the National Health Interview Survey, National Center for Health Statistics, 1987. age 70 are generally less likely to have had an exam, a problem that is more pronounced for older blacks and Hispanics.
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From page 82... ...
CUnpublished data from the National Health Interview Survey, National Center for Health Statistics, 1987. dConfidence interval.
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From page 83... ...
For example, data from one large, multisite, surveybased study show that a much higher proportion of women have had a clinical breast exam (between 46 and 76 percent) than have undergone mammography (between 25 and 41 percent; National Cancer Institute, Breast Cancer Screening Consortium, 1990b)
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From page 84... ...
65.7 17.7 7.6 9.0 SOURCE: Unpublished data from the National Health Interview Survey, National Center for Health Statistics, 1987. reason (National Cancer Institute, Breast Cancer Screening Consortium, 1990b)
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From page 85... ...
As was true for breast cancer screening, data from the NHIS indicate that poor or less educated women are less likely than nonpoor or welleducated women to undergo Pap testing. The majority of reasons cited by women for not obtaining a Pap test reflected a lack of appreciation of the importance of screening rather than cost considerations or lack of access to a physician.
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From page 86... ...
To accomplish this, questions should be added to the BRFSS surveys to collect information about insurance status, income, and regular source of care. Outcome Indicator: Incidence of Late-Stage Breast and Cervical Cancers Late-stage cancers are those that have invaded contiguous tissues and organs or that have spread through the blood or lymphatic system to other parts of the body.
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From page 87... ...
The age-adjusted death rate from breast cancer for white women was 23 per 100,000; for blacks it was 27 per 100,000. Whites also have higher five-year survival rates than blacks (National Center for Health Statistics, l990b)
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From page 88... ...
bAtlanta, San Francisco/Oakland, Connecticut, Seattle, and Detroit. and white women in the proportion of breast cancers diagnosed at late stages.
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From page 89... ...
Public Health Service, 19911. In one study the cumulative incidence of invasive cervical cancer was reduced almost 84 percent when Pap tests were conducted every five years; it was reduced nearly 93 percent when the interval between testing was reduced to two years (International Agency for Research on Cancer, Working Group on Evaluation of Cervical Cancer Screening Programmes, 1986~.
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From page 90... ...
bLow income is the bottom 10 percent and high income the top 20 percent of all cases distributed by per-capita income of the county of residence. SOURCE: Unpublished data from the SEER program.
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From page 91... ...
Continuing care for a chronic illness may include periodic tests to monitor a patient's health status, nutritional and other types of counseling to reduce or eliminate patient behaviors that may be harmful to health, and necessary medications and medical and surgical procedures. Underuse of the health care system by those with chronic diseases as reflected by few or irregular physician visits or a less than optimal regimen of care may indicate an access problem.
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From page 92... ...
Measuring the Indicator There is no direct, routinely available way to measure the use of particular follow-up health care services for specific chronic diseases, like diabetes, that could be used to measure barriers to access. Periodically, however, the extent to which patients with a particular disease have contact with the personal health care system has been documented through supplements to the NHIS.
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From page 93... ...
Table 3-19 compares such people with different types of insurance coverage. In 1989 the uninsured were more than twice as likely as those with private health insurance, Medicaid, or Medicare to go without physician contact.
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From page 94... ...
Medicare and private health insurance 6 6 5 5 aInsurance definitions are as follows: Medicaid only if the person has a current Medicaid card or is covered by Aid to Families with Dependent Children, Supplemental Security Income, or public assistance and has no other insurance coverage; Medicare plus other health insurance Medicare plus either private insurance, Medicaid, or CHAMPUS/ Veterans Administration or military health insurance. Private health insurance includes only people who reported private insurance and no other types of insurance.
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From page 95... ...
Private health insurance includes only people who reported private insurance and no other types of insurance. SOURCE: Unpublished data from the National Health Interview Survey, National Center for Health Statistics, 1989.
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From page 96... ...
SOURCE: Unpublished data from the National Health Interview Survey, National Center for Health Statistics, 1989. Recommendations Longitudinal Survey of individuals with Chronic Diseases.
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From page 97... ...
SOURCE: Unpublished data from the National Health Interview Survey, National Center for Health Statistics, 1989. ease by providing patients with continuing and meaningful contact with the personal health care system.
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From page 98... ...
The National Center for Health Statistics should determine whether this modification could best be done through changes in core sections of the survey (e.g., supplementary questions to the condition list) or through regularly rotating supplements that include appropriate access questions.
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From page 99... ...
One national study of hospital discharge abstracts revealed that uninsured patients were between 29 and 75 percent less likely than those with insurance to undergo one of five high-cost or high-discretion procedures: coronary artery bypass surgery, total knee replacement, total hip replacement, stapedectomy, and surgical correction of strabismus (Hadley et al., 1991~. Similar findings were reported for the use of angiography, angioplasty, and cardiac bypass grafting among patients treated in Massachusetts hospitals.
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From page 100... ...
SOURCE: Joint data and analysis by the Codman Research Group, the Ambulatory Care Access Project (United Hospital Fund of New York) , and the IOM Access Monitoring Committee.
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From page 101... ...
Trends in the Data Because the methodology for this utilization indicator is new, there are no year-to-year trend data. Table 3-24 presents aggregated data for 1988 from the states in the committee's sample of hospital discharge data bases.
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From page 102... ...
Although hospital admission rates are generally a utilization measure, they are used here as a proxy for health conditions that have deteriorated to the point where hospitalization is required. Ongoing medical management can effectively control the severity and progression of a number of chronic diseases, even if the diseases themselves cannot be prevented.
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From page 103... ...
No matter how timely or effective outpatient medical management may be, a certain amount of hospitalization among patients with chronic diseases is expected. If differences in disease prevalence are taken into account, however, there should be no major differences in hospital admission rates according to income level, insurance status, or race.
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From page 104... ...
Small pockets of the poor in otherwise high-income areas, as well as dispersal of the poor across a wide region, can be particularly problematic. Although information about health insurance status is included on the standard hospital discharge form, there are no good data on insurance status by geographic area.
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From page 105... ...
, examining New York City discharge data, looked at the effects of race, substance abuse, and prevalence of disease conditions on the differences between high- and low-income areas. They found that predominantly black middle-income zip codes resembled other middle-class areas but that poor black areas had consistently higher admission rates than comparable white low-income zip codes.
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From page 106... ...
Outcome Indicator: Access-Related Excess Mortality The access-related excess mortality rate is the number of deaths per 100,000 population that are thought to be the result of access problems. The estimate is based on a comparison of two groups in the populationone that is believed to have relatively good access and one that is considered likely to experience barriers to access.
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From page 107... ...
In addition to questions of methodology, some conceptual issues also need to be resolved. Foremost among these is the dilemma of how to handle chronic disease behavioral risk factors for example, hypertension that could be ameliorated by treatment or care and whose presence may indicate barriers to access to health care services.
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From page 108... ...
This estimate is based on applying "rate ratios" derived from an epidemiological study that compared risk factors among blacks and whites (Often et al., 19901. The difference between the first and second rates represents the excess mortality of blacks that is related to lack of access to health care services.
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From page 109... ...
The areas indicated are the estimated mortality for blacks if age-specific mortality rates were equal to those of whites ~ ~ ) ; the estimated excess black mortality due to differences in controllable risk factors ~ Cal; and estimated excess black mortality due to differences in access to personal health care (my.
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From page 110... ...
As mentioned, the rate ratios that are used to adjust for the effect of a set of risk factors for the 1970s were used to calculate access-related excess mortality in 1988. Without new risk data, however, only part of the story can be revealed.
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From page 111... ...
The committee believes that research on access-related excess mortality must begin to focus on specific diseases, particularly those amenable to access-related prevention services or amelioration. The present analysis would have been enhanced by the availability of data from a somewhat older age cohort in which chronic diseases were a higher fraction of all deaths.
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From page 112... ...
Data on physician contacts, perceived health status, and restricted activity days are available from the NHIS. Roughly 800 million physician contacts are made each year by people believing themselves to be in good or excellent health.
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From page 113... ...
This indicator attempts to measure this concern by singling out healthy people who suddenly become so sick that they must reduce their normal activities. The question is whether such characteristics as insurance status, income, and race have an effect on whether they obtain medical attention.
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From page 114... ...
SOURCE: Unpublished data from the National Health Interview Survey, National Center for Health Statistics, 1989. terms of their use of ambulatory care.
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From page 115... ...
In conjunction with efforts to improve monitoring of continuing care for chronic diseases, the NCHS should explore methods to better understand the timely and appropriate use of physician services during episodes of acute illness. Of particular interest are acute illnesses and early stages of chronic illness that have the potential for serious consequences if left untreated.
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From page 116... ...
A monitoring method must be able to disaggregate the content of dental visits to determine when the kind of dental care received is related to problems with access. To sort out the effects of financial barriers, it would be desirable to have more refined information about insurance coverage for dental services.
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From page 117... ...
For 1983 the categories are less than $10,000; $10,000-$18,999; $19,000-$29,999; $30,000-$39,999; and $40,000 or more. SOURCE: Unpublished data from the National Health Interview Surveys, National Center for Health Statistics, 1964, 1983, 1989.
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From page 118... ...
Hence, the higher incidence of dental diseases and the presence of high levels of untreated oral conditions suggest that Hispanic American adults experience problems in gaining access to dental care that can compromise the quality of their adult lives (Ismail and Szpunar, 1990~. Household income was directly related to the use of dental services (see Table 3-27~.
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From page 119... ...
as likely to be admitted to hospitals for dental conditions as those from high-income zip codes. Hospital admission for the specific set of ICD-9 TABLE 3-28 Annual Dental Visits, by Dental Insurance Status and Selected Characteristics, 1986 and 1989 Private Insurance Uncovered Characteristic 1986 1989 1986 1989 Total 2.6 2.7 1.7 1.7 Race Black 2.0 1.7 1.1 0.9 White 2.7 2.8 1.8 1.8 Family income Less than $1O,000 2.9 2.1 1.2 1.2 $10,000-$19,999 1.9 2.1 1.5 1.3 $20,000-$34,999 2.6 2.3 2.1 1.8 $35,000 or more 2.9 3.1 2.4 2.5 SOURCE: Unpublished data from the National Health Interview Surveys, National Center for Health Statistics, 1986 and 1989.
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From page 120... ...
Questions in future NHIS dental supplements should gather information not only about private insurance coverage but also about publicly funded coverage, such as that provided by Medicaid, Medicare (for oral surgery) , the Department of Veterans Affairs, and the military (for dependents)
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From page 121... ...
(See the discussion for the indicator "Routine Physician Contacts" above.) The personal health care system in some cases provides only symptomatic relief to patients for conditions that would resolve independent of any medical intervention.
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From page 122... ...
For instance, these services might include nutrition education for new mothers to lower rates of gastrointestinal diseases, screening young women for venereal disease to lower their rates of pelvic inflammatory disease, or addiction services for alcoholics who are at risk of various medical complications. As in the previous indicators that use hospital discharge data, this indicator is measured by the ratio of hospital admissions from low-income zip codes to admissions from high-income zip codes; High-ir~come areas are
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From page 123... ...
For most of the diagnoses in the table, the rates of hospital admissions from low-income zip codes were two to five times higher than rates from high-income zip codes. The overall average ratio was 3.69.
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From page 124... ...
188. Hyattsville, Md.: National Center for Health Statistics.
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From page 125... ...
1991. Reducing Infant Mortality: The Research Gaps.
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From page 126... ...
1985. Preventing Low Birthweight.
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From page 127... ...
1990. The effect of known risk factors on the excess mortality of black adults in the United States.
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From page 128... ...
1991. Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans.
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From page 129... ...
New York: United Hospital Fund of New York/Greater New York Chapter of the March of Dimes.
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