Access, Quality and Satisfaction with Care: Volume 24

This chapter provides an introduction to the volume and reviews some issues related to access, quality and satisfaction with care as three critical concepts in health services and health care delivery. In addition to this review of some of the material on access, quality and satisfaction with care, this chapter also serves as an introduction to the volume. As such, the chapter explains the organization of the volume and briefly comments on each of the chapters included in the volume.

The objectives of the current interim report are to measure the extent of the access to care problem, identify and compare the types of patient- and system-based barriers experienced by Vietnam veterans at risk for suicide when seeking care for physical, psychiatric, and substance abuse conditions, analyze patient-perceived quality of care for individuals who obtained access to care, and identify how the care-seeking experience effected future care seeking. This study is based on a longitudinal sample of 494 Vietnam veterans discharged from military service in September 1971 and subsequently identified as at risk for suicide (306 low risk; 188 high risk). Seventy-one percent (350) of 494 participants completed an extensive qualitative and quantitative interview covering, among other topics, physical conditions, psychiatric conditions, substance use, barriers to care, facilitators of care, and quality of care. Barriers, satisfaction, and effect of the experience were compared by type of condition and suicidal risk category using χ2 analysis and Fisher's as appropriate. The analysis is based on 257 interviews (73 percent) with qualitative data transcribed thus far. Results: Of the 195 patients with self-reported health conditions, 76 (39.0 percent) and 45 (23.1 percent) expressed system-based barriers to care, respectively. The group at higher risk of suicide was significantly more likely (p<0.01) to report patient-based barriers to care and system-based barriers to care (p<0.05), and more likely (p<0.05) to experience negative effects of the care-seeking experience. Both self-perceived and system-based barriers to care pose obstacles for patients at high risk of suicide. Targeted interventions are required to reach out to these patients to address needs for care currently unmet by the health care system and to reduce negative effects of the health care experience.

The number of uninsured has increased during recent years. This study explores underlying factors associated with the insurance-status disparities in hospital care by examining 80,730 acute myocardial infarction discharges in the National Inpatient Sample. Compared to patients having private insurance, Medicaid patients’ higher mortality risk related to severity of illness while the higher mortality of uninsured patients related to interactive effects between insurance status and hospital characteristics. Primary care strategies are likely to improve the hospital care for Medicaid patients while ensuring access to high quality care for patients with limited financial means can improve outcomes for uninsured patients.

Despite the biological and clinical advances in oral health, dental disease is still a problem for those of low socioeconomic (SE) status, as well as racial and ethnic minorities. In this study, we use the Andersen Behavioral Model of predisposing, enabling, and need factors to examine the effects of race, ethnicity, and income on dental care utilization. Using the Medical Expenditure Panel Survey (MEPS) household component and dental event data (n=8,685), we tested the hypothesis that longer survival or delay in dental care utilization is associated with both minority and lowered SE statuses. Analyses confirm that minority status, income, and education, are predictive of the delay in dental care utilization. This study lends support to the theorized assumption that there are racial and ethnic differences in the pattern of dental care utilization and that these differences as well as other factors contribute to disparity in dental care utilization.

Frequently women are attended by someone other than their chosen doctor during labor and delivery, that is, an “on-call” doctor. This chapter draws from interviews with 19 women who gave birth in a Mid-Atlantic state during late 1995 and early 1996. Of these women, 13 received care from an on-call doctor. Using existing social–psychological perspectives, the authors analyze situations in which an on-call doctor was present, and how this provider influenced women's birth experiences as well as satisfaction with those experiences. In general, women do not expect or desire on-call doctors’ presence. As a result, they may rely on obstetric nurses, rather than these unfamiliar doctors, when they need information or support.

The problems of providing high-quality care in nursing homes have been extensively documented. Accounts of residents, close family members, and qualitative researchers have described feelings of desperation, anomie, and hopelessness, which accompany the last years, months and days of those reluctantly finding themselves in institutional facilities at the end of their days. However sociologists have, thus far, paid little attention to the actual and potential impact of families in breaking through the barriers set up by institutional life and in enhancing the responsiveness of care in nursing homes. This chapter aims to fill this gap.

For frail older persons, gaining access to care is primarily in the context of long-term care institutions. Based on hypotheses derived from the theory of the total institution (Goffman, 1961) and anticipatory socialization theory (Merton & Kitt, 1950), linkages of intra-institutional and extra-institutional social ties with quality of life outcomes were assessed based on 168 residents’ self-reports of their life and problems experienced in long-term care (Kahana, Kahana, & Young, 1987). Findings reveal that lack of anticipatory socialization was a significant predictor of subsequent wellbeing, whereas the extent of social ties to the outside world did not predict subsequent wellbeing.

In a climate of ongoing political, economic, technological, and cultural changes in Western, Central, and Eastern Europe, this chapter describes the kinds of changes happening with the health care system and the preparation of health care professionals in one selected country, that of Hungary. Emphasis will be focused on the nursing sub-sector of the health system. Some comparison and contrast will be done between these systems in Hungary and the U.S. Changes will be presented in the context of the European Union and the Bolonga Declaration.

This chapter examines the relationship between health service restructuring and the health care experiences of women from rural and remote areas of Canada. Data were collected from 34 focus groups (237 women), 15 telephone interviews and 346 responses from an online survey. Access to services, care quality and satisfaction are salient themes in these data. Problems include: travel, shortage of providers, turnover in personnel, delays associated in accessing care, lack of knowledge of women's health issues and patronizing attitudes of some health care providers. Health care service restructuring has led to deterioration in service availability and quality. Key areas for policy development need to address health care access and quality improvement issues, including increasing access to more (particularly female) providers who are sensitive to women's health issues.

The study assesses public health programs to shed light on the experiences of low-income and minority women with children seeking health services. Thirteen focus groups were conducted with 111 pregnant women or women with children. Women consumers of public health services experience difficulties accessing health services due to a lack of insurance, information and language barriers about programs and eligibility, a shortage of Medicaid providers and specialist services, long waits, bureaucratic barriers, and dismissive treatment. Accessibility and information barriers were more prominent in rural regions whereas bureaucratic barriers were more pronounced in urban areas. Lower satisfaction with services was reported among ethnic minority women compared to whites.

Improving access and the quality of health services requires community health initiatives. However, in order for such efforts to be successful, there has to be some agreement at the community level as to which community initiatives ought to be pursued. With diversity of population, health disparities, limited resources, and competing needs, agreement is unlikely; instead a negotiated consensus among key stakeholders (community advocates, agency leaders, service providers, and consumers) must be developed. A negotiated consensus takes into account differences and allows for some kind of resolution of these differences in order to achieve a given end. A negotiated consensus is necessary for the identification of common goals, prioritizing these goals, and either seeking funding or utilizing available funding for selected community initiatives. The chapter examines efforts by a regional health care system which fostered community initiatives in four diverse sites. We develop a framework which can guide other community initiatives in health care.