Woods Charles R, Arcury Thomas A, Powers James M, Preisser John S, Gesler Wilbert M
Department of Pediatrics, Wake Forest University School of Medicine, Winston Salem, North Carolina 27157-1084, USA.
Pediatrics. 2003 Aug;112(2):e143-52. doi: 10.1542/peds.112.2.e143.
To assess determinants of health care visits among children in a 12-county region of western North Carolina representative of rural areas in the United States.
Households were randomly selected for surveys of household characteristics, health status, and health care use. Surveys were conducted June 1999 to January 2000 and were stratified for children younger than 5 years and 5 years and older. The number of health care visits in the year before the survey was used as the outcome measure. Weighted mean visits and associations of family demographic and child health variables with the number of visits were determined by ratio and multivariate survey regression methods.
Among children who lived in rural Appalachian regions of North Carolina in 1999, 90% had either public or private insurance coverage. The mean number of visits per child was 5.7 (median: 2.6), and in each age group the number of visits in the previous year exceeded the recommended number of well-child visits. There were no apparent geographic access barriers to care in this population, in that increased distances to provider sites did not result in declining numbers of visits. For children younger than 5 years, the primary determinants of health care use during the previous year were age, insurance status, and household income. Infants had more visits than older, preschool children, and those with household incomes >40 000 dollars per year had 76% more visits than those with incomes <20 000 dollars per year. Children with public insurance, exclusively Medicaid in this population, had almost 4 times as many visits as uninsured children. Among the children and adolescents 5 through 17 years of age, health insurance status, household income, pain during the past month, and race were the primary determinants of health care use during the previous year. Those with public health insurance had 6 times more health care visits than uninsured children. Household incomes >40 000 dollars per year were associated with 2.5-fold increased health care visits, and those with household incomes between 20 000 dollars and 40 000 dollars per year had 2-fold increased health care visits, compared with those with household incomes <20 000 dollars per year. White children had almost twice as many visits in the past year as black children in this age group. Pain experienced during the past month, as perceived by the parent, also predicted the number of visits in the older age group.
This rural population seems to have reasonably good access to care overall. The key determinants of health care use among these rural children were similar to those found in urban and other populations in the United States and likely are universal: health insurance coverage, household income, and parent perceptions of their child's pain. As in other populations, programs in rural areas that strengthen health insurance coverage and reduce poverty will have a direct impact on child health. Differential use of health care among white and black children, especially those 5 years and older, merits additional explanation.
评估美国北卡罗来纳州西部12县农村地区儿童医疗就诊的决定因素。
随机选取家庭进行家庭特征、健康状况及医疗服务使用情况的调查。调查于1999年6月至2000年1月进行，并按5岁及以下儿童和5岁以上儿童分层。将调查前一年的医疗就诊次数作为结果指标。通过比率法和多变量调查回归方法确定加权平均就诊次数以及家庭人口统计学和儿童健康变量与就诊次数的关联。
1999年居住在北卡罗来纳州农村阿巴拉契亚地区的儿童中，90%拥有公共或私人保险。每个儿童的平均就诊次数为5.7次（中位数：2.6次），且在各年龄组中，前一年的就诊次数均超过了推荐的健康儿童就诊次数。该人群在获得医疗服务方面没有明显的地理障碍，因为到医疗机构距离的增加并未导致就诊次数减少。对于5岁及以下儿童，前一年医疗服务使用的主要决定因素是年龄、保险状况和家庭收入。婴儿的就诊次数多于年龄较大的学龄前儿童，家庭年收入超过40000美元的儿童比年收入低于20000美元的儿童就诊次数多76%。拥有公共保险（该人群中仅为医疗补助）的儿童就诊次数几乎是未参保儿童的4倍。在5至17岁的儿童和青少年中，健康保险状况、家庭收入、过去一个月的疼痛情况和种族是前一年医疗服务使用的主要决定因素。拥有公共健康保险的儿童就诊次数是未参保儿童的6倍。与家庭年收入低于20000美元的儿童相比，家庭年收入超过40000美元的儿童就诊次数增加了2.5倍，家庭年收入在20000美元至40000美元之间的儿童就诊次数增加了2倍。在这个年龄组中，白人儿童过去一年的就诊次数几乎是黑人儿童的两倍。家长感知到的过去一个月的疼痛情况也可预测年龄较大组儿童的就诊次数。
该农村人群总体上似乎有较好的医疗服务可及性。这些农村儿童医疗服务使用的关键决定因素与美国城市及其他人群中发现的因素相似，且可能具有普遍性：健康保险覆盖、家庭收入以及家长对孩子疼痛的感知。与其他人群一样，农村地区加强健康保险覆盖和减少贫困的项目将对儿童健康产生直接影响。白人和黑人儿童在医疗服务使用上的差异，尤其是5岁及以上儿童，值得进一步解释。
