Bindman A B, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, Billings J, Stewart A
Primary Care Research Center, San Francisco General Hospital, CA 94110, USA.
JAMA. 1995 Jul 26;274(4):305-11.
To examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style.
Analysis of California hospital discharge data. We calculated the hospitalization rates for these five chronic conditions for the 250 ZIP code clusters that define urban California. We performed a random-digit telephone survey among adults residing in a random sample of 41 of these urban ZIP code clusters stratified by admission rates and a mailed survey of generalist and emergency physicians who practiced in the same 41 areas.
Community based.
A total of 6674 English- and Spanish-speaking adults aged 18 through 64 years residing in the 41 areas were asked about their access to care, their chronic medical conditions, and their propensity to seek health care. Physician admitting style was measured with written clinical vignettes among 723 generalist and emergency physicians practicing in the same communities.
We compared respondents' reports of access to medical care in an area with the area's cumulative admission rate for these five chronic conditions. We then tested whether access to medical care remained independently associated with preventable hospitalization rates after controlling for the prevalence of the conditions, health care seeking, and physician practice style.
Access to care was inversely associated with the hospitalization rates for the five chronic medical conditions (R2 = 0.50; P < .001). In a multivariate analysis that included a measure of access, the prevalence of conditions, health care seeking, and physician practice style to predict cumulative hospitalization rates for chronic medical conditions, both self-rated access to care (P < .002) and the prevalence of the conditions (P < .03) remained independent predictors.
Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions.
探讨低收入社区中哮喘、高血压、充血性心力衰竭、慢性阻塞性肺疾病和糖尿病等慢性疾病较高的住院率是否源于社区在医疗服务可及性、疾病患病率、就医倾向或医生收治方式上的差异。
对加利福尼亚州医院出院数据进行分析。我们计算了定义加利福尼亚城市的250个邮政编码区域内这五种慢性病的住院率。我们对居住在按住院率分层的41个城市邮政编码区域随机样本中的成年人进行了随机数字电话调查，并对在相同41个区域执业的全科医生和急诊医生进行了邮寄调查。
基于社区。
居住在41个区域的总共6674名年龄在18至64岁之间、讲英语和西班牙语的成年人被询问了他们获得医疗服务的情况、慢性疾病状况以及就医倾向。通过书面临床案例对在同一社区执业的723名全科医生和急诊医生的收治方式进行了测量。
我们将一个区域内受访者关于获得医疗服务的报告与该区域这五种慢性病的累计住院率进行了比较。然后，在控制了疾病患病率、就医情况和医生执业方式后，我们测试了获得医疗服务是否仍然与可预防的住院率独立相关。
获得医疗服务与五种慢性疾病的住院率呈负相关（R2 = 0.50；P <.001）。在一项多变量分析中，纳入了获得医疗服务的指标、疾病患病率、就医情况和医生执业方式以预测慢性疾病的累计住院率，自我报告的获得医疗服务情况（P <.002）和疾病患病率（P <.03）仍然是独立的预测因素。
人们认为医疗服务可及性差的社区，慢性病住院率较高。改善医疗服务可及性比改变患者的就医倾向或消除医生执业方式的差异更有可能降低慢性病的住院率。
