gapha conference the_determinantsoftimelyaccesstoqualityhealthcare_chineloogbuanu_final_041211
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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?