Center for Home Care Policy and Research, Visiting Nurse Service of New York, 5 Penn Plaza, 12th Floor, New York, NY 10001, USA.
Soc Sci Med. 2012 Sep;75(5):914-21. doi: 10.1016/j.socscimed.2012.04.029. Epub 2012 May 23.
Disparities in primary care access and quality impede optimal chronic illness prevention and management for older adults. Although research has shown associations between neighborhood attributes and health, little is known about how these factors - in particular, the primary care infrastructure - inform older adults' primary care use. Using geographic data on primary care physician supply and surveys from 1260 senior center attendees in New York City, we examined factors that facilitate and hinder primary care use for individuals living in service areas with different supply levels. Supply quartiles varied in primary care use (visit within the past 12 months), racial and socio-economic composition, and perceived neighborhood safety and social cohesion. Primary care use did not differ significantly after controlling for compositional factors. Individuals who used a community clinic or hospital outpatient department for most of their care were less likely to have had a primary care visit than those who used a private doctor's office. Stratified multivariate models showed that within the lowest-supply quartile, public transit users had a higher odds of primary care use than non-transit users. Moreover, a higher score on the perceived neighborhood social cohesion scale was associated with a higher odds of primary care use. Within the second-lowest quartile, nonwhites had a lower odds of primary care use compared to whites. Different patterns of disadvantage in primary care access exist that may be associated with - but not fully explained by - local primary care supply. In lower-supply areas, racial disparities and inadequate primary care infrastructure hinder access to care. However, accessibility and elder-friendliness of public transit, as well as efforts to improve social cohesion and support, may facilitate primary care access for individuals living in low-supply areas.
初级保健的可及性和质量差距阻碍了老年人对慢性病的最佳预防和管理。尽管研究表明社区属性与健康之间存在关联，但对于这些因素（特别是初级保健基础设施）如何告知老年人的初级保健使用情况，人们知之甚少。利用纽约市 1260 名老年人中心参与者的初级保健医生供应的地理数据和调查，我们研究了在服务供应水平不同的地区，哪些因素促进和阻碍了个人对初级保健的使用。供应四分位数在初级保健使用（过去 12 个月内就诊）、种族和社会经济构成以及感知邻里安全和社会凝聚力方面存在差异。在控制了构成因素后，初级保健的使用并没有显著差异。那些主要在社区诊所或医院门诊部就诊的人比那些主要在私人医生办公室就诊的人进行初级保健就诊的可能性更小。分层多变量模型表明，在供应最低的四分位数中，公共交通使用者比非交通使用者更有可能进行初级保健。此外，邻里社会凝聚力量表的得分较高与进行初级保健的几率较高相关。在第二低供应四分位数中，与白人相比，非白人进行初级保健的几率较低。初级保健可及性方面存在不同的劣势模式，这些模式可能与当地初级保健供应有关（但不能完全解释）。在供应较低的地区，种族差异和初级保健基础设施不足阻碍了获得护理的机会。然而，公共交通的可达性和对老年人友好性，以及改善社会凝聚力和支持的努力，可能会为居住在供应不足地区的个人提供初级保健。
