Department of Sociology, Rutgers University, New Brunswick, NJ 08901, USA.
BMC Health Serv Res. 2010 Sep 10;10:269. doi: 10.1186/1472-6963-10-269.
Utilization of specialty care may not be a discrete, isolated behavior but rather, a behavior of sequential movements within the health care system. Although patients may often visit their primary care physician and receive a referral before utilizing specialty care, prior studies have underestimated the importance of accounting for these sequential movements.
The sample included 6,772 adults aged 18 years and older who participated in the 2001 Survey on Disparities in Quality of Care, sponsored by the Commonwealth Fund. A sequential logit model was used to account for movement in all stages of utilization: use of any health services (i.e., first stage), having a perceived need for specialty care (i.e., second stage), and utilization of specialty care (i.e., third stage). In the sequential logit model, all stages are nested within the previous stage.
Gender, race/ethnicity, education and poor health had significant explanatory effects with regard to use of any health services and having a perceived need for specialty care, however racial/ethnic, gender, and educational disparities were not present in utilization of specialty care. After controlling for use of any health services and having a perceived need for specialty care, inability to pay for specialty care via income (AOR = 1.334, CI = 1.10 to 1.62) or health insurance (unstable insurance: AOR = 0.26, CI = 0.14 to 0.48; no insurance: AOR = 0.12, CI = 0.07 to 0.20) were significant barriers to utilization of specialty care.
Use of a sequential logit model to examine utilization of specialty care resulted in a detailed representation of utilization behaviors and patient characteristics that impact these behaviors at all stages within the health care system. After controlling for sequential movements within the health care system, the biggest barrier to utilizing specialty care is the inability to pay, while racial, gender, and educational disparities diminish to non-significance. Findings from this study represent how Americans use the health care system and more precisely reveals the disparities and inequalities in the U.S. health care system.
专科医疗的利用可能不是一个离散的、孤立的行为，而是医疗系统内的一系列连续动作。尽管患者通常会先看他们的初级保健医生并接受转诊，然后再利用专科医疗，但之前的研究低估了考虑这些连续动作的重要性。
该样本包括 6772 名 18 岁及以上的成年人，他们参加了 2001 年由英联邦基金会赞助的《医疗质量差异调查》。使用序贯逻辑模型来解释利用专科医疗的所有阶段的变化：利用任何卫生服务（即第一阶段）、认为需要专科医疗（即第二阶段）和利用专科医疗（即第三阶段）。在序贯逻辑模型中，所有阶段都嵌套在前一个阶段内。
性别、种族/民族、教育程度和健康状况不佳对利用任何卫生服务和认为需要专科医疗有显著的解释作用，但在利用专科医疗方面没有出现种族/民族、性别和教育程度的差异。在控制了利用任何卫生服务和认为需要专科医疗之后，无法通过收入（AOR=1.334，CI=1.10 至 1.62）或健康保险（不稳定保险：AOR=0.26，CI=0.14 至 0.48；无保险：AOR=0.12，CI=0.07 至 0.20）支付专科医疗费用是利用专科医疗的重要障碍。
使用序贯逻辑模型来检查专科医疗的利用情况，可以详细地描述利用专科医疗的行为和影响这些行为的患者特征，这些行为在医疗系统的各个阶段都存在。在控制医疗系统内的连续动作后，利用专科医疗的最大障碍是无法支付费用，而种族、性别和教育程度的差异则减少到不显著的程度。本研究的结果代表了美国人如何利用医疗保健系统，更准确地揭示了美国医疗保健系统中的差异和不平等。
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