SRAP Community Health Access Survey: Selected Analyses and Discussion

1
SRAP Community Health Access Survey Selected
Analyses and Discussion
SRAP Grantee Conference February 24, 2005 Little
Rock

• Donald Pathman
• University of North Carolina at Chapel Hill

2
Presentation Overview

• Assess how peoples access to care in the rural
  South relates to the distribution of physicians
• Compare the access of African Americans and
  Whites in the rural South

3
Physicians and Access.You Tell Me . . .

• For your town/city/ neighborhood/county
• Is it important to have a certain number of
  doctors, or a certain proportion of doctors to
  population?
• For policy makers
• Is it important to support policies to
  promote approximately the same number of
  physicians per population in all geographic
  areas?

4
Perceived Importance Physician Distribution

• Presumed to be a fundamental aspect of access
• Long travel to physician care is thought to be
  the fundamental access problem in rural areas
• The focus of numerous federal and state programs
• SRAP
• National Health Service Corps
• Medicares Incentive Payment Program in
  underserved areas

5
COGME 10th Report
6

• Why does a community need a certain, adequate
  number of local doctors?
• What gets better when more doctors are around?

7
Model of Outcomes of Local Availability of
Physicians
More docs present locally
Better access to care
Better health
8
Model of Outcomes of Local Access to Physicians
More docs present locally

• More have usual source of care
• More have a doctor visit each year
• Fewer report inability to get care
• More have recommended preventive care

Better access to care
Better health
9

• Have studies shown that more local physicians
  actually yield better access to care?

10
Urban Access

• Little association found between local urban
  physician numbers, use of services and other
  access indicators
• Insurance and affordability are key urban
  peoples access

11
Physician Supply and Rural Access

• Only 2 studies (with 1970s data) available
• Compared access in rural physician shortage vs.
  non-shortage areas
• Found no access differences in number of
  physician visits, perceptions of barriers to care
  or satisfaction with care.
• Found rural physician scarcity areas had longer
  travel times for care, longer office wait times,
  lower use rates for some preventive health
  services and, in one study, lower likelihood of
  having usual source of care.

Berk, Bernstein, Taylor. The use and
availability of medical care in Health Manpower
Shortage Areas. Inquiry 1983. Kleinman and
Wilson. Are Medically Underserved Areas
medical underserved? Health Serv Res 1977.
12
Council on Graduate Medical Education

• COGME. Tenth Report. Physician Distrib. and
  Health Care Challenges in Rural and Inner-City
  Areas, 1998.
• Few studies have been undertaken to
  systematically compare access to care in shortage
  and non-shortage communities, and they have
  serious flaws.
• Evidence supports
• longer travel times but same number of visits
• income, insurance, race and need for care key
  issues in access in rural access

13
Are Local Physician Numbers Important in Rural
Areas?

• Since the 1970s
• physician numbers have more than doubled in all
  size rural communities
• medicine relies more on regionalized specialty
  care and technology
• rural roads have improved
• rural people routinely travel distances for work,
  shopping and entertainment
• local rural community is less central in peoples
  lives

14
Question to be Answered for SRAP states

• How does local physician availability relate to
  access in the rural Southeast?
• a region where physician numbers are lower than
  elsewhere
• access to medical care is poorer by some measures
• local physician access was assumed to be
  important in the design of the SRAP

15

• SRAP Health Care Access Survey

Donald Pathman Jennifer Groves Thomas
Ricketts Samruddhi Thaker Thomas R.
Konrad Larry LoganJennifer Albright
16
SRAP Access Survey

• Survey of access in SRAP-targeted counties
  part of the programs evaluation
• Access to
• outpatient routine care (primary care)
• for adults
• over previous 12 months
• Used questions from previous national surveys,
  published studies, and some new items

17
SRAP Access Survey

• Random digit dialing telephone survey
• P.R.C., Inc. of Omaha
• English and Spanish
• November 2002 July 2003

18
SRAP Access Survey

• Target population
• 150 rural counties (omitted SRAP urban
  counties)
• 2,520,000 adult population

19
Southern Rural Access Program (SRAP)
August 21, 2003 Produced By North Carolina
Program on Health Professionals and Primary Care,
Cecil G. Sheps Center for Health Services
Research, University of North Carolina at Chapel
Hill.
20
SRAP Health Care Access Survey

• 4,879 respondents
• 600 respondents per state
• 51.0 overall response rate

21
Research Questions

• How do local primary care physician to population
  ratios relate to adults access to outpatient
  medical care in the rural Southeast?

22
Research Questions

• How do local primary care physician to population
  ratios relate to adults access to outpatient
  medical care in the rural Southeast?
• Is local primary care physician availability more
  important for the access of the rural elderly and
  poor?

23
Analyses

• Analyses weighted for gender, age, income and
  race, and county participation likelihood

24
Analyses

• Analyses weighted for gender, age, income and
  race, and county participation likelihood
• Analyses conducted at the Primary Care Service
  Area (PCSA) group level
• ZIP codes clustered (Goodman, HSR, 2003)
• 298 PCSAs among the 150 rural counties
• five groups of pop-to-primary care doc ratios
  lt1,500 1,500-1,999 2,000-2,499 2,500-3,499
  3,500

25
Analyses

• Analyses weighted for gender, age, income and
  race, and county participation likelihood
• Analyses conducted at the Primary Care Service
  Area (PCSA) group level
• Analyses controlled for gender, age,
  race-ethnicity, employment, household income,
  health status, insured/uninsured, PCSA population
  size, minority population in PCSA, households
  below poverty in PCSA

26
PCSA Weighted Group Respondent Characteristics
(N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• 1,499 1,999 2,499 3,499
• n 1,432 1,119 504 511 745 p
• gt age 65 17.9 16.6 17.5 20.3 20.1
  .36
• non-Hisp. White 64.9 60.4 59.9 56.3 60.8
  .02
• with HH income 43.8 45.1 43.8 48.9 45.8
  .55
• lt 25,000
• w/o insurance 21.8 26.6 23.5 27.1 26.7
  .06

27
Pop/Physician Ratios and Use of Services (N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• 1,499 1,999 2,499 3,499
• Had no physician visit
• in past year
• Had no routine
• check-up
• Did not get
• needed care
• Delayed needed care

28
Pop/Physician Ratios and Use of Services (N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• 1,499 1,999 2,499 3,499 adj. p
• Had no physician visit 19.7 19.6 22.0 18.7 17.
  2 ns
• in past year
• Had no routine 23.9 22.7 26.3 21.2 21.4
  ns
• check-up
• Did not get 12.1 13.9 10.7 12.9 13.7 ns
• needed care
• Delayed needed care 30.2 30.5 29.1 25.7 31.0
  ns

29
Pop/Physician Ratios and Reported Barriers to
Care (N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• 1,499 1,999 2,499 3,499 adj. p
• Routine care generally 13.6 14.9 11.6 15.3 14.
  6 ns
• difficult to get
• Costs of care are a 23.2 26.3 25.1 20.9 26.8
  ns
• problem
• Has no usual source 16.3 12.9 14.6 11.9 13.6
  nsof care
• Difficult getting appt. 13.6 12.8 10.9 8.9 13.
  0 ns
• in 1-2 days

30
Pop/Physician Ratios and Reported Barriers to
Care (N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• 1,499 1,999 2,499 3,499 adj. p
• Difficult contacting 16.4 18.0 17.9 16.9 17.7
  ns
• doctor by phone
• gt 40 minute office 21.5 21.7 19.3 17.2 19.3
  ns
• wait
• Travels gt 30 minutes 18.5 24.9 30.0 38.6 39.1
  lt.01
• for care
• Finds travel for care 10.9 10.1 11.7 12.5 15.
  5 lt.01
• difficult

31
Pop/Physician Ratios and Dissatisfaction with
Care (N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• Dissatisfied with. . . 1,499 1,999 2,499 3,499
• care overall
• quality of care
• doctors concern
• getting questions
• answered
• feeling welcome and
• comfortable

32
Pop/Physician Ratios and Dissatisfaction with
Care (N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• Dissatisfied with. . . 1,499 1,999 2,499 3,499
  adj. p
• care overall 7.7 9.1 6.6 7.0 8.9 ns
• quality of care 7.6 6.5 7.1 4.7 5.6 ns
• doctors concern 7.8 6.0 7.7 5.5 4.8 ns
• getting questions 7.0 6.6 5.8 4.8 6.0 ns
• answered
• feeling welcome and 6.7 7.3 6.8 5.6 6.9
  ns
• comfortable

33
Pop/Physician Ratios and Reported Preventive Care
(N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• 1,499 1,999 2,499 3,499 adj. p
• Adults gt 50 w/o ever 45.9 49.8 47.6 48.4 55.0
  ns
• sigmoid/colonoscopy
• Women gt 50 w/o 37.4 37.6 31.8 36.1 40.2
  ns
• mammogram
• Women 18 - 65 w/o 5.4 4.2 4.7 1.3 10.9
  ns
• Pap smear in 3 years

34
Pop/Physician Ratios and Reported Preventive Care
(N4,311)

• Greatest Least
• 0- 1,500- 2,000- 2,500- 3,500
• 1,499 1,999 2,499 3,499 adj. p
• Adults gt 65 years 27.7 34.3 21.2 28.1 42.1 lt
  .05
• w/o flu shot
• Adults w/o diet 51.6 55.1 54.5 53.2 50.6
  ns
• counseling
• Adults w/o exercise 49.7 51.0 53.4 51.6 49.9
  ns
• counseling

35
Pop/Physician Ratios and Access for Elderly

• Greatest Least
• 0 -1499 1500-2799 2800 adj. p
• Travels gt 30 minutes 24.5 28.9
  33.3 lt.01
• for care

36
Pop/Physician Ratios and Access for Those 18-65
with Medicaid or Uninsured

• Greatest Least
• 0 -1499 1500-2799 2800
• Travels gt 30 minutes 17.1 29.3 36.4
• for care
• Finds travel for care 13.8 16.9 25.0
• difficult
• Difficulty contacting doctor 22.8 25.2 27.0
  
• by phone
• Overall dissatisfied 10.8 13.01 17.0
• with care
• Not feeling welcome 8.1 13.1 13.8
• and comfortable

37
Conclusions

• For rural adults as a whole and the elderly in
  the rural Southeast, more physicians per
  population locally means greater travel
  convenience but otherwise is not important to
  access.
• Lack of local physicians is somewhat important to
  access for the poor.
• Need to be critical in our programs intended to
  even out the distribution of physicians
• target the areas where critical shortages are
  affecting access
• transportation services are part of a solution
• make sure new physicians are accessible to poor
• support initiatives to improve quality of care
• addressing peoples economic barriers more
  important

38
But People Still Feel There Arent Enough Local
Doctors. Why?
Holly Biola, MD
I feel there are enough doctors in my community
39
Due to numerical shortages?
Holly Biola, MD
Believes there are enough physicians in community
County population per physician
40
Factors Associated with Perceived Physician
Adequacy

• D.V.Belief there are enough doctors
• Physicians per 1,000 population 1.18 .002
• Age over 65 1.37 .006
• Male 1.26 .011
• White 1.37 .001
• Good/Excellent health status 1.21 .048
• Travel lt30minutes to care 1.52 lt.001
• Cost of care is not a problem 1.69 lt.001
• Believe illnesses resolve w/o care, seeing
  doctors should be last resort 1.99 lt.001
• Satisfied with care received this year 1.67 .023
• Confident in their doctors abilities to
  help 1.39 .006

41

• Discussion about physician availability and
  access in rural south?

42

• Access of African Americans compared to Whites
  in rural SRAP counties

Donald Pathman, MD MPH Giselle Corbie-Smith, MD
MPH Angela Fowler-Brown, MD MPH
43
2003 National Healthcare Disparities Report (AHRQ)

• Areas outpatient access worse for Black than
  White adults
• Fewer have health insurance
• Fewer have usual source of care
• More use ER for usual source of care
• More had no office visits in past year
• More dissatisfied with their overall care
• Fewer obtain prenatal care in first trimester
• Fewer gt 65 years immunized against influenza
• Fewer women had mammography
• Fewer had sigmoidoscopy/colonoscopy

44
2003 National Healthcare Disparities Report

• Areas outpatient access comparable or better for
  Black than White adults
• Can get care as soon as wanted
• Receive needed health care
• Had blood pressure checked
• Had blood cholesterol checked
• Had Pap smear for cervical cancer screening
• Smokers received advice to quit
• Feel their physician listens carefully to them
• Had no difficulty understanding health information

45
Limitations of Past Black-White Access Studies

• Based primarily on nationwide surveys
• primarily reflect urban situations, rural samples
  too small omit issues relevant in rural areas
  (travel)
• majority (75) of rural African-Americans live
  in six states of US Southregional confounding in
  studies with national data

46
Questions for SRAP States

• How does access to outpatient physician services
  differ for African-American and White adults
  living in the rural Southeast?
• What factors account for the differences?

47
Use SRAP Access Survey Data

• Limited these analyses to respondents from 113
  counties in six states with substantial rural
  African-American populations (dropped TX and
  WV)
• 1,183,184 African-Americans lived here (1990)
• Analyses involved
• 1,237 non-Hispanic Blacks
• 2,158 non-Hispanic Whites

48
Study States and Counties
49
Findings Group Comparisons

• Blacks Whites p
• (n1,237) (n2,158)
• Age
• 18-39 years 46.3 36.8 lt.0001
• 65 years and older 13.3 20.8
• Self-Reported
• Fair or poor health 27.3 21.0 .0002

50
Findings Group Comparisons

Blacks Whites p Education lt high school
completion 23.4 15.7 lt.0001 Employment
Not employed 46.3 41.3 .02 Household
annual income lt 14,999 42.1 19.1
lt.0001 15,000 24,999 21.0 13.5
51
Use of Health Services
Control
for Age, Gender, Unadjusted Health
No outpatient visits in Blacks previous
year Whites Mean outpatient Blacks visits
in past year Whites
Time in past year Blacks when did not
get Whites needed medical care
Time in past year Blacks when delayed
getting Whites needed medical care
52
Use of Health Services
Control
for Age, Gender, Unadjusted Health
No outpatient visits in Blacks 18.2 0.99 previo
us year Whites 18.5 Mean outpatient
Blacks 5.8 - - visits in past year
Whites 4.6
Time in past year Blacks 15.8 1.39 when
did not get Whites 10.2needed medical care
Time in past year Blacks 29.3 0.86 when
delayed getting Whites 29.4needed medical care
lt.05 lt.01 lt.001
53
Use of Health Services
Control for
Age Control for Gender, Health,
Age, Gender, Educa, Income,
Unadjusted Health Employ
No outpatient visits in Blacks 18.2 0.99
0.90 previous year Whites 18.5 Mean
outpatient Blacks 5.8 - - - - visits
in past year Whites 4.6
Time in past year Blacks 15.8 1.39
1.16 when did not get Whites 10.2needed
medical care
Time in past year Blacks 29.3 0.86
0.83 when delayed getting Whites 29.4needed
medical care
lt.05 lt.01 lt.001
54
Barriers
O.R. for Blacks Relative to Whites
Control for
Age, Gender, Unadjust
Health
Reports it is generally difficult Blacks 17.4
1.67 to get routine medical
care Whites 10.1 when needed Adults lt 65
years currently Blacks 37.5 1.92
without any health insurance Whites 23.5
Reports the costs of care are more Blacks 25.1 0.
98 than a minor problem for them Whites 23.2

lt.05 lt.01 lt.001
55
Barriers
O.R. for Blacks Relative to Whites
Control for Age
Control for Gender, Health,
Age, Gender, Educa,
Income, Unadjust Health
Employ
Reports it is generally difficult Blacks 17.4
1.67 1.27 to get routine
medical care Whites 10.1 when needed Adults
lt 65 years currently Blacks 37.5 1.92
1.31 without any health
insurance Whites 23.5
Reports the costs of care are more Blacks 25.1 0.
98 0.82 than a minor problem for
them Whites 23.2
lt.05 lt.01 lt.001
56
Adjusting for Community Resources

• How did these Black-White differences in
  perceived barriers change by further controlling
  for county medical resources?
• physician/population ratios
• presence of a FQHC
• presence of an acute care hospital
• adjacency to an urban county

57
Adjusting for Community Resources

• How did these Black-White comparisons in use of
  services change by further controlling for county
  medical resources?
• physician/population ratios
• presence of a FQHC
• presence of an acute care hospital
• adjacency to an urban county
• Not one bit!

58
Adjusting for Community Resources

• How did these Black-White comparisons in use of
  services change by further controlling for county
  medical resources?
• physician/population ratios
• presence of a FQHC
• presence of an acute care hospital
• adjacency to an urban county
• Not one bit!
• NONE of the B-W differences in this studys
  access indicators sensitive to county medical
  resources.
• To save time I wont show these findings.

59
Barriers
O.R. for Blacks Relative to Whites
Control for
Age, Gender, Unadjust
Health
No usual source of med care Blacks 16.1
1.69 Whites 11.0 Usually seeks
care in ER Blacks 10.6 2.82
Whites 3.9
Travels gt 40 minutes for care Blacks 16.0
1.14 Whites 15.2 Finds travel for care is
difficult Blacks 13.7 1.79
Whites 7.9
lt.05 lt.01 lt.001
60
Barriers
O.R. for Blacks Relative to Whites
Control for Age
Control for Gender, Health,
Age, Gender, Educa, Income,
Unadjust Health Employ
No usual source of med care Blacks 16.1
1.69 1.36 Whites 11.0
Usually seeks care in ER Blacks 10.6
2.82 2.13 Whites 3.9
Travels gt 40 minutes for care Blacks 16.0
1.14 1.14 Whites 15.2 Finds travel for
care is difficult Blacks 13.7 1.79
1.42 Whites 7.9
lt.05 lt.01 lt.001
61
Perceived Racial Barriers
O.R. for Blacks Relative to Whites
Control for Age
Control for Gender, Health,
Age, Gender, Educa, Income,
Unadjust Health Employ
Believes that peoples race/ethnicity
Blacks 54.1 4.40 3.83
is often a barrier to health care
Whites 22.9 in their community
lt.05 lt.01 lt.001
62
Office Barriers
O.R. for Blacks Relative to Whites
Control
for Age, Gender,
Unadjust Health
Difficult to get appt. within 1-2
days Blacks 13.9 1.33 Whites 10.0 Diffi
cult to contact doctor by phone Blacks 16.9 0.96
Whites 16.7 Waits gt 40 minutes in office
Blacks 20.9 1.15 Whites 18.5
lt.05 lt.01 lt.001
63
Office Barriers
O.R. for Blacks Relative to Whites
Control for Age
Control for Gender, Health,
Age, Gender, Educa, Income,
Unadjust Health Employ
Difficult to get appt. within 1-2
days Blacks 13.9 1.33 1.07 Whites 10.0
Difficult to contact doctor by phone Blacks 16.9
0.96 0.86 Whites 16.7 Waits gt
40 minutes in office Blacks 20.9
1.15 1.05 Whites 18.5
lt.05 lt.01 lt.001
64
Satisfaction
O.R. for Blacks Relative to Whites
Control for Age
Control for Gender, Health,
Age, Gender, Educa, Income,
Unadjust Health Employ
Not satisfied overall with care Blacks 9.7
1.62 1.42 received Whites 5.6 Not
satisfied with quality of care Blacks 6.6
1.11 0.96 received Whites 5.3 Not
confident in their providers Blacks 25.4
1.73 1.52 ability to help them
with their Whites 15.4 medical problems
lt.05 lt.01 lt.001
65
Satisfaction
O.R. for Blacks Relative to Whites
Control for Age
Control for Gender, Health,
Age, Gender, Educa,
Income, Unadjust Health
Employ
Not satisfied with concern shown Blacks 7.5
1.60 1.34 by their doctors for them and
Whites 4.2their health Not satisfied with
getting their Blacks 6.3 1.22 1.07 health
questions answered during Whites 4.8office
visits
lt.05 lt.01 lt.001
66
Preventive Services
O.R. for Blacks Relative to Whites
Control for Age
Control for Gender, Health,
Age, Gender, Educa, Income,
Unadjust Health Employ
Adults gt 65 yrs without flu shot Blacks 49.5
2.83 2.41 in past year
(n447) Whites 25.5 Women gt 50 yrs who had
no Blacks 39.6 0.93
0.75 mammography in past year (n655) Whites 40.0
Women 18-65 yrs without a Blacks 5.8 1.05
0.79 hysterectomy who had no
Pap Whites 5.0 smear in past 3 years (n931)
lt.05 lt.01 lt.001
67
Preventive Services
O.R. for Blacks Relative to Whites
Control for Age
Control for Gender, Health,
Age, Gender, Educa, Income,
Unadjust Health Employ
Adults gt 18 yrs who received Blacks 48.8
0.80 0.71 no diet or
nutrition counseling Whites 55.0 in past year
(n2,383) Adults gt 18 yrs who received Blacks 48
.8 0.90 0.77 no advice
about exercise or Whites 51.6 physical activity
(n2,391) Adults gt 18 yrs who use
tobacco Blacks 44.9 2.11
1.92 and were not advised to
quit Whites 28.5 in past year (n645)
lt.05 lt.01 lt.001
68
Summary Black vs. White Access in Rural South

• Outpatient access worse for Black than White
  adults
• As found in national comparisons
• Fewer have health insurance
• Fewer have usual source of care
• More use ER for usual source of care
• More perceive racial barriers to care
• More dissatisfied with their care overall
• Fewer immunized against influenza
• Not noted in national data
• More find care generally hard to get
• More forgo needed care
• Fewer confident their physician can help them
• Fewer satisfied with their physicians concern
  for them
• Fewer smokers advised to quit

69
Summary Black vs. White Access in Rural South

• Outpatient access same or better for Black than
  White adults
• As found in national comparisons
• Can get care when needed
• Doctor communication and patient education good
• Had Pap smear
• Not noted in national data (i.e., situation
  better for Blacks in South than elsewhere)
• Had office visit in past year
• Had mammogram in past year

70

• Discussion