Miscellaneous |
Lower utilization of primary, specialty and preventive care services by individuals residing with persons in poor health
Basile Chaix1, Maryam Navaie-Waliser2, Cecile Viboud3, Isabelle Parizot1 and Pierre Chauvin1
1 Research Unit in Epidemiology and Information Systems and Modelling, National Institute of Health and Medical Research (INSERM U707), Paris, France
2 Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY, USA
3 Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
Correspondence: Basile Chaix, INSERM U707, Faculté de Médecine Saint-Antoine, 27 rue Chaligny, 75571 Paris Cedex 12, France, tel: +33 1 44 73 84 43, fax: +33 1 44 73 86 63, e-mail: chaix{at}u707.jussieu.fr
Received April 29, 2004, accepted February 23, 2005
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Abstract |
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Background: Since household time and financial resources for health care are primarily spent for those household members with the most urgent health needs, individuals residing with persons in poor health may be at risk of underusing health-care services. We examined whether these individuals had a lower use of primary, specialty and preventive care than those who did not reside with persons in poor health. Methods: Data collected in 2000 from a representative sample of 8210 French individuals aged 18 years and older from 3810 households were analysed with logistic regression models adjusted for health, demographic and socioeconomic variables. Results: We found that individuals residing with one other survey respondent had a higher risk of not using primary care, specialty care and preventive care in the 12 months preceding the study when the health status of the other survey respondent was poorer (fair or alternatively poor versus good). Furthermore, individuals residing with two other survey respondents had a higher risk of not using primary care, specialty care and preventive care in the 12 months preceding the study when they resided with a higher number of respondents in fair or poor health (one or alternatively two versus zero). Conclusion: The lower use of health services by individuals residing with persons in poor health may signal a need for health practitioners to broaden the scope of care beyond their patients, and for policy makers to consider the long-term impact of this situation on the health-care system.
Keywords: family caregivers, family health, health service use
On one hand, medical advances have enabled people with serious and chronic illness to survive longer despite their health problems.1 On the other hand, in recent years, the health-care systems of many Western countries have experienced trends towards shortened hospital stays and expanded outpatient care services.2–5 These recent changes have made living with persons in poor health a common experience. It is well known that many individuals residing with persons in poor health play an important part in health-care delivery as family caregivers. Increased risks of stress,1,6–14 distress,2,3 depressive symptoms1,2,12,14–19 and poor physical health2,4,12,17,19,20 have been reported for these family caregivers, and have often been attributed in the literature to the hardship of the caregiving activity. Public health researchers have extensively investigated the utilization patterns of the services providing support to family caregivers.5,21,22 However, few studies have examined whether individuals residing with persons in poor health actually receive adequate health care for their own health concerns. Since household time1,2,6,9,23 and financial1,11,24 resources for health care are primarily spent for those household members with the most urgent health needs, individuals residing with persons in poor health may be at risk of underusing health-care services.
The literature on this question is very sparse. A North American study has ascertained that caregivers of senile dementia patients had a greater number of visits to their physician and a greater number of prescription medications (for their own health concerns) than their matched non-caregiver controls.12 On the other hand, a Californian study of elderly members of a large health maintenance organization reported no significant difference in routine physical examinations between caregivers and non-caregivers.25 In both studies, however, measures of association were not adjusted for each individual's health status. Therefore, the use of health-care services by caregivers and non-caregivers cannot be appropriately compared, since the two groups are not comparable in terms of their health status and their resulting health-care needs (see references above).
Considering the shortcomings in the literature we: (i) took into account the potential confounding effects of the health status and sociodemographic characteristics; (ii) considered all the adults residing with persons in poor health rather than only the effective family caregivers, so that our findings would have widespread generalizability; and (iii) investigated utilization patterns of several types of health-care services. Our study expands former research in this area by examining whether individuals residing with persons in poor health have a lower use of primary, specialty and preventive care than people who have not been cast in such a situation.
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Methods |
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Source of data
Cross-sectional data were collected in 2000 by the French National Institute of Statistics and Economic Studies (INSEE) through a face-to-face interview survey. Households were randomly drawn from the INSEE master sample (a list of households made at the time of each census that constitutes a pool from which all INSEE survey samples are drawn in the period between two censuses26). Survey questionnaires were completed by 5413 (79%) out of the 6824 households selected. Up to three persons aged 15 years or older were surveyed in each household. When there were more than three such persons in the household, three were randomly selected for an interview. During scheduled interview times, 28% of the pre-selected individuals were absent. Their questionnaires were completed by another household member. Data were collected by trained interviewers using structured survey questionnaires, which captured demographic characteristics, health characteristics, socioeconomic variables (including precise financial indicators) and information on health-care utilization.
For the purposes of this study, individuals surveyed who were under 18 years of age (n = 464) were excluded from the study sample, so that individuals who may have little decision-making power over health-care utilization were not included. Individuals who had no other surveyed household member (n = 1599) were also excluded from the analyses. Twenty-one individuals were further excluded because of incomplete information on health-care utilization. In the end, the study sample consisted of 8210 individuals aged 18 years or older from 3810 households with two or three survey respondents. Weighting coefficients were computed by INSEE to ensure that the sample was representative of the French population in terms of age, gender and employment status.
Statistical analysis
The three binary outcome variables were based on the following survey questions posed to respondents: ‘Over the previous 12 months: (i) Have you consulted a primary care physician? (ii) Have you consulted a specialist physician (of any kind)? (iii) Have you had medical tests or clinical examinations performed for preventive purposes?’ For each question, respondents had to choose between the following answers: ‘yes, one time’; ‘yes, two or three times’; ‘yes, more than three times’; or ‘no, never’. The three binary outcomes indicated whether each individual had or had not used (i) primary care physician consultations, (ii) specialist physician consultations and (iii) preventive care in the 12 months preceding the study (1 = no use; 0 = at least one utilization).
Weighted multilevel logistic models27,28 with individuals nested within households were fitted for each outcome variable. Since health, demographic and socioeconomic factors have repeatedly been shown to be associated with health-care utilization, they were progressively introduced into the models in order to control for potential confounders. These variables are listed and extensively detailed in table 1.29,30 Our purpose was to disentangle the effect of residing with persons in poor health from other interactions between household members, such as mimicry of health-care utilization behaviour between such household members. Accordingly, for improved adjustment of the model for the utilization of a given service, we considered whether individuals residing with persons who did not use that specific service in the 12 months preceding the study had an increased risk of not using it themselves (see bottom of table 1). Furthermore, we took into account the potential confounding effect of other-reported, rather than self-reported, health service utilization for those individuals who were absent at the time of the interview: the models were adjusted for the presence/absence of individuals.
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For every individual aged 18 years or older, we took into account the other persons aged 15 years or older surveyed in their household in defining the explanatory variable of interest (health status of the other persons surveyed in the household). Therefore, a given individual was considered both as an individual from the study sample and as a household member for one or two other individuals in the sample.
Separate regression models were fitted for individuals residing with one other survey respondent and for those residing with two other survey respondents. The models were used to test the following hypotheses. (i) Individuals residing with one other survey respondent had a higher risk of not using health-care services in the 12 months preceding the study when the health status of the other respondent was poorer (fair or alternatively poor versus good). (ii) Individuals residing with two other survey respondents had a higher risk of not using health-care services in the 12 months preceding the study when they resided with a greater number of respondents in fair or poor health (one or alternatively two versus zero).
First, we estimated models that took into account only the health status of co-residents and the number of other household respondents who had not used the health-care service over the previous 12 months. In order to assess the potential confounding role played by the health status of individuals, we then included the different health variables (reported health status, chronic disease, sick leave and home assistance). In a third step, demographic and socioeconomic variables were introduced into the model.
All multilevel model parameters were estimated with MLwiN 1.2 software (Institute of Education, London, UK). Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed.
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Results |
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In the sample, 18% of the individuals did not use primary care services, and 45% had not used specialty care services in the 12 months preceding the study. Fifty-eight percent of the individuals had used no preventive health-care services in the 12 months preceding the study. Twenty-seven percent of the individuals were in poor health, and 45% in fair health. Overall, 23% of individuals resided only with persons in good health. Thirty-one percent resided with at least one person in poor health. Regarding health-care utilization of the co-residents, 13%, 37% and 52% of the individuals, respectively, had no co-residents who had used primary, specialty or preventive care over the previous 12 months. Many individual-level explicative variables were found to differ between those residing and those not residing with persons in fair or poor health (table 2). In particular, individuals residing with persons in fair or poor health had a markedly higher risk of being in fair or poor health themselves, and this association remained after adjustment for demographic and socioeconomic variables (results not shown).31
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In all our models (before and after adjustment for health, demographic and socioeconomic variables), individuals residing with survey respondents who did not use a given health-care service had increased risks of not using that service themselves in the 12 months preceding the study (tables 3
–5).
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In the models that were not adjusted for health and sociodemographic variables (table 3), residing with persons in fair or poor health was not associated with health-care utilization, except in the case of specialty and preventive care for individuals residing with two other survey respondents. When health variables were included into the models (table 4), consistent associations between residing with persons in fair or poor health and utilization of health-care services appeared in all the models, indicating that health status was a major confounding factor (see Discussion).
Individuals residing with one other survey respondent had a higher risk of not using health-care services in the 12 months preceding the study when the health status of the other survey respondent was poorer (fair or alternatively poor versus good) (table 4). The association was linear and significant for each of the three types of health-care services (i.e. primary, specialty and preventive care). Moreover, individuals residing with two other survey respondents had a higher risk of not using health-care services in the 12 months preceding the study when they resided with a greater number of respondents in fair or poor health (one or alternatively two versus zero) (table 4). The association was linear and significant for each of the three types of health-care services. As indicated in table 5, even if the strength of association diminished slightly in most of the cases, all these associations remained significant and dose-response when demographic and socioeconomic variables were introduced into the models.
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Discussion |
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Our study addresses an important topic that has received minimal attention in the scientific literature, namely the utilization of health-care services by individuals residing with persons in poor health. Building on the earlier literature, the study provides a broader outlook by showing that residing with persons in poorer health or with a higher number of persons in fair or poor health has adverse and dose–response effects on the likelihood of using three different types of health-care services (primary, specialty and preventive care).
Limitations of the study
There are several limitations to our study. First, 21% of the households refused to participate in the survey. This is not a particularly significant rate of non-participation for such population surveys; however, we had almost no information on those households that refused to participate, and were therefore not able to assess how it could have affected the associations reported here. Secondly, for certain individuals in the study sample, we did not have information for all the household members (household residents under 15 years of age and certain individuals in households where there were more than three persons 15 or older were not surveyed). Survey data with information on all members of a household would be useful in order to obtain more accurate estimates of the risks incurred by individuals residing with persons in poor health. Thirdly, utilization of health-care services was other-reported, rather than self-reported, for the pre-selected individuals who were absent at the time of the interview. The inclusion in models of a dummy variable for the presence/absence of the individuals indicated that those individuals who did not personally complete the survey questionnaire had a higher risk of being classified as non-users of specialty care (the effect was not significant for primary care and preventive care). Therefore, our estimates of the percentage of individuals who did not use specialty care in the 12 months preceding the study may be biased towards overestimation. However, the impact that residing with persons in fair or poor health had on specialty care utilization remained unchanged after adjusting the model for the presence/absence of the individuals scheduled to be interviewed.
Interpretation of the findings
In our study, consistent associations between residing with persons in poor health and utilization of health-care services were found only when adjusting for the health status of the respondents, indicating that this variable was a major confounder. In health-care utilization research, it is common to adjust findings on risk factors of lower utilization for the health status of individuals. Indeed, residing with persons in poor health is a risk factor of lower utilization only if those people living with sick persons have a lower utilization of services than individuals with similar health-care needs who do not reside with persons in poor health. Our findings indicate that studies investigating the association between residing with persons in poor health and health-care utilization, without adjusting for the respondents' own health status, may be misleading.
In France, individuals can consult any physician of their choice (primary care physician or specialist) as frequently as they wish.29 Every legal resident is entitled to basic health coverage, and user charges that are not reimbursed by national Social Security (6 euros for a primary care consultation, with higher prevailing fees for specialists) are refunded by supplementary elective insurance plans. In 2000, 93% of the population carried this extra insurance.32 Therefore, even if there may not be major income-related barriers for access to health care in France, some people without supplementary insurance, or with supplementary insurance of a lower quality, may find it quite expensive to access certain specialized health-care services.
In this context, several causal pathways may be suggested for associations between residing with persons in poor health and the utilization of health-care services. First, individuals residing with persons having considerable medical expenses may have to spend less money on their own health to allow for the increased health-care costs of their ill household members. The financial barrier may be reinforced because individuals residing with such persons in especially poor health may consider spending money for their health care unwarranted in view of the more serious and urgent health-care needs of their ill household members. Secondly, other mechanisms not directly related to financial resources may also play a part in certain situations, such as the time involved and the drain on affective resources. The caregiving literature reports that family caregivers experience subjective and objective burdens13,18,21,22,33–37 leading to the disruption of daily life and the restriction of activity.1–3,12,16,38–40 Therefore, certain individuals residing with persons with a particularly deteriorated health status may be objectively and subjectively too overburdened by their caregiving activity to mind their own health.23,41 Finally, individuals residing with persons in poor health may downplay the importance of their own health problems in view of the problems of their ill household members and may, therefore, have a lower than expected utilization of health-care services.
Some of the causal pathways described above (increased health-care costs and increased caregiving burden) may only hold true for individuals residing with persons in especially poor health. However, in our study, even those residing with persons in fair health had lower than expected utilization of the three types of services cited earlier. Additional study may gain more insight into the causal pathways at play.
Implications for policy and practice
We identified a risk factor of lower use of several types of health-care services that has almost never been investigated in Europe or North America. Findings similar to the ones reported here may be expected in other industrialized countries, although with minor changes owing to differences in health-care systems.
Although we found that individuals residing with persons in poor health had a lower use of medical services, we were not able to compare their levels of utilization with existing recommendations or expressed needs. Therefore, we were not able to demonstrate whether this lower utilization corresponds to underutilization of care for many such individuals residing with persons in poor health. This realistic interpretation of our findings may constitute a relevant hypothesis for future research. In a public health perspective, underuse of health-care services by individuals residing with persons in poor health would signal a need for health practitioners to broaden the scope of care beyond the patients themselves and move toward a household-centred model of care. For example, in accordance with a study that has underscored that primary care physicians are in a good position to identify caregivers at risk,20 physicians might be encouraged to turn their attention to those living with their very ill patients.
In addition, if further research concludes there is a risk of underuse of health-care services by individuals residing with ill persons, policy makers will have to consider the long-term impact of this situation on the health-care system. First, health-care costs may be higher in an intervention-driven model of care than in a prevention-driven model of care, where individuals residing with persons in poor health might benefit from the regular use of ambulatory care. Secondly, since many individuals residing with persons in poor health play an important role as family caregivers, their underuse of health care may not allow them to remain healthy in the long run and may lead to the increased use of the formal care system by the care-receiving household members, or even to the institutionalization of these care recipients. Tailoring policies to ensure that those residing with persons in poor health receive the benefit of regular use of ambulatory care (including preventive care) may be a cost-saving strategy as well.
Key points
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Acknowledgments |
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B.C. carried out this work with a doctoral grant, and with a grant from the French Ministry of Research (TTT027). The project was supported by the ‘Avenir 2002’ programme of INSERM (the French National Institute of Health and Medical Research).
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