3
Using Indicators to Monitor National Objectives for Health Care

As noted earlier, the committee believes that assessing access to health care requires more than a simple tally of the use of services. The content and appropriateness of those services also must be estimated. Implicit in the committee's definition of access is the idea that certain services improve health. Thus, for many, if not most, personal health care services, there is an expectation of benefit, and that benefit extends beyond such obviously important outcomes as avoiding death to more subtle quality-of-life values like physical and social functioning.

With these concepts in mind, the committee focused on access problems that it believes, if corrected, are most likely to lead to improved health outcomes on a wide scale. Indicators were then identified that could be used to measure changes in the degree of access to specific health care services. After considerable discussion, the committee agreed on a list of 15 indicators, which were grouped into several distinct categories. The categories define a set of national objectives for the personal health care system, with each set of indicators providing a means of assessing progress toward a specific objective. The objectives are as follows: (1) promoting successful birth outcomes; (2) reducing the incidence of vaccine-preventable childhood diseases; (3) early detection and diagnosis of treatable diseases; (4) reducing the effects of chronic diseases and prolonging life; and (5) reducing morbidity and pain through providing timely and appropriate treatment. Table 3-1 shows for each objective the related indicators, how they are measured, and the latest year for which data are available.



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Access to Health Care in America 3 Using Indicators to Monitor National Objectives for Health Care As noted earlier, the committee believes that assessing access to health care requires more than a simple tally of the use of services. The content and appropriateness of those services also must be estimated. Implicit in the committee's definition of access is the idea that certain services improve health. Thus, for many, if not most, personal health care services, there is an expectation of benefit, and that benefit extends beyond such obviously important outcomes as avoiding death to more subtle quality-of-life values like physical and social functioning. With these concepts in mind, the committee focused on access problems that it believes, if corrected, are most likely to lead to improved health outcomes on a wide scale. Indicators were then identified that could be used to measure changes in the degree of access to specific health care services. After considerable discussion, the committee agreed on a list of 15 indicators, which were grouped into several distinct categories. The categories define a set of national objectives for the personal health care system, with each set of indicators providing a means of assessing progress toward a specific objective. The objectives are as follows: (1) promoting successful birth outcomes; (2) reducing the incidence of vaccine-preventable childhood diseases; (3) early detection and diagnosis of treatable diseases; (4) reducing the effects of chronic diseases and prolonging life; and (5) reducing morbidity and pain through providing timely and appropriate treatment. Table 3-1 shows for each objective the related indicators, how they are measured, and the latest year for which data are available.

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Access to Health Care in America TABLE 3-1 Access Indicators Objective/Indicator Measure Latest Data Available 1. Promoting successful birth outcomes Adequacy of prenatal care (u) Percentage of pregnant women obtaining adequate care 1988 Infant mortality (o) Children who die before first birthday (per 1,000 live births) 1990 Low birthweight (o) Percentage of infants born weighing less than 2,500 grams 1988 Congenital syphilis (o) Cases per 100,000 population 1990 2. Reducing the incidence of vaccine-preventable preventable childhood diseases Immunization rates (u) Percentage of preschool children vaccinated 1985 Incidence of preventable childhood communicable diseases (diphtheria, measles, mumps, pertussis, polio, rubella, and tetanus) (o) Cases per 100,000 population 1989 3. Early detection and diagnosis of treatable diseases Breast and cervical cancer screening (u) Percentage of women undergoing procedure in given period     • Clinical breast exam 1987   • Mammogram 1990   • Pap test 1987 Incidence of late-stage breast and cervical cancers (o) Percentage of tumors diagnosed at late stages     • Breast cancer 1983–1987   • Cervical cancer 1983–1987

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Access to Health Care in America Objective/Indicator Measure Latest Data Available 4. Reducing the effects of chronic diseases and prolonging life Chronic disease follow-up care (u) Average number of physician contacts annually by those in fair to poor health; proportion with no physician contacts in previous year 1989 Use of high-cost discretionary care (u) Admissions for referral-sensitive surgeries 1988 Avoidable hospitalization for chronic diseases (o) Admissions for ambulatory-care-sensitive chronic conditions 1988 Access-related excess mortality (o) Number of deaths per 100,000 population estimated to be due to access problems 1988 5. Reducing morbidity and pain through timely and appropriate treatment Acute medical care (u) Percentage of individuals with acute illness who have no physician contact 1989 Dental services (u) Average number of dental visits per year 1989 Avoidable hospitalization for acute conditions (o) Admissions for ambulatory-care-sensitive conditions 1988 u, utilization; o, outcome.

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Access to Health Care in America The sections that follow discuss one or more utilization and outcome indicators for each objective. An indicator is first defined and the rationale for including it in the report is presented. This is followed by a subsection on measurement and an analysis of any methodological or measurement problems. A third subsection discusses overall trends in the data related to the particular indicator and, where possible, includes specific information on racial and ethnic groups. It also describes and provides data on barriers to access faced by various groups (the uninsured, the less educated, etc.) in the population. The final subsection contains the committee's recommendations. The committee did not attempt to develop its own quantitative goals for the indicator measures. Where possible, the Year 2000 Health Objectives for the Nation goals are cited as a benchmark and to indicate existing consensus about the desired levels of service use or health status. Time series data are explored to indicate improvement or lack of improvement over the past decade. Finally, comparisons among population subgroups are made and constitute a major focus for interpretations. OBJECTIVE 1: PROMOTING SUCCESSFUL BIRTH OUTCOMES Utilization Indicator: Adequacy of Prenatal Care Prenatal care consists of medical services and procedures intended to monitor and maintain the health of mother and fetus from conception to delivery. For the purposes of this report, prenatal care at a minimum consists of periodic examinations to screen for and manage health risks to the mother and developing fetus. Prenatal visits comprise an accurate medical history, physical exam (including a check of blood pressure), and laboratory tests (including tests for serum glucose levels, sexually transmitted diseases, and cervical cancer). The results of these periodic visits will determine the necessary degree of monitoring and intervention. For example, a woman found to have gestational diabetes, abnormal weight gain, signs of premature labor, or preeclampsia (hypertension of pregnancy) may require more frequent visits to the obstetrician or certain nonstandard medical procedures or tests. Women at high risk for poor pregnancy outcomes—such as those who smoke, those who suffer from malnutrition or nutritional imbalance, or those who are addicted to drugs or alcohol—may need to take part in a wide range of medical, health education, and social service programs. The content of prenatal care can vary widely depending on the patient's needs, what health care services are available, and which of the available services the patient chooses to take advantage of. Extensive efforts have been made to evaluate the components of prenatal care. The Public Health Service's Expert Panel on the Content of Prenatal

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Access to Health Care in America Care has analyzed a large constellation of services and procedures that constitute prenatal care. The panel reviewed the scientific and medical literature to determine the efficacy and appropriate timing of more than 130 individual components of prenatal care (Public Health Service Expert Panel on the Content of Prenatal Care, 1989). Another major recent effort to define the content of prenatal care is the seventh edition of Standards for Obstetric-Gynecological Services published in 1989 by the American College of Obstetricians and Gynecologists. Numerous studies have shown the link between the timing, amount, and content of prenatal care and successful birth outcomes. Prenatal care also has been shown to be cost effective, particularly for poorly educated, low-income women who otherwise might incur significant direct medical expenses for the care of their low birthweight infants (Institute of Medicine, 1985, 1988; Office of Technology Assessment, 1988). The committee realizes that a woman's general health status prior to becoming pregnant has a significant impact on the course and outcome of her pregnancy. Nevertheless, the prenatal period is of critical importance because a host of interventions are known to make a significant difference in the outcome of a pregnancy, regardless of the mother's prior health history. Two aspects of a woman's access to health care services and her health-seeking behavior prior to pregnancy are worth noting. First is the use and content of so-called preconception medical care, which has been shown to have a direct influence on the later use of prenatal care services. Women are much more likely to use prenatal care services during their pregnancy when the pregnancy is planned (and the child is wanted) than when it is unplanned or mistimed (and the child is unwanted). Noting that more than half of all pregnancies in the United States are unwanted, the IOM Committee to Study Outreach for Prenatal Care concluded that more extensive use of family planning services (a ''preconception" service) would result in reduced rates of late entry into prenatal care (Institute of Medicine, 1988). The second aspect is the role, indirect and direct, that nutrition services, particularly the Special Supplemental Food Program for Women, Infants, and Children (WIC), play in improving maternal and infant health. WIC is among those services ancillary to prenatal care that have great potential for enhancing the outcome of pregnancy. There is considerable evidence that WIC participation reduces rates of low birthweight and infant mortality (Caan et al., 1987; Centers for Disease Control, 1978; Coit, 1977; Collins et al., 1985; Food Research Action Center, 1991; Kennedy and Kotelchuck, 1984; Rush et al., 1988b; Schramm, 1986). Other research (Kotelchuck et al., 1984; Rush et al., 1988a; U.S. Department of Agriculture, 1990) has shown that women who participate in the WIC program enter early prenatal care more often than women who are eligible but do not participate. A large proportion of women who are eligible to participate in the WIC program

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Access to Health Care in America do not do so. In 1984, for example, although some 7.5 million women, infants, and children were eligible, only slightly more than 3 million received WIC benefits (U.S. Department of Agriculture, 1987). It is generally believed that lack of knowledge about available benefits and administrative barriers to enrollment are in great measure to blame for lack of access to the program. Measuring the Indicator The primary source for data on prenatal care is the birth certificate. The data are reported by states annually to the National Center for Health Statistics (NCHS). Another important source of information about prenatal care is the 1988 National Maternal and Infant Health Survey (National Center for Health Statistics, 1991), which gathered data from mothers and their health care providers. There are two aspects of prenatal care that are frequently measured: its initiation and frequency. When a woman first obtains prenatal care is important because care initiated early in a pregnancy has the best chance of preventing or treating medical conditions that could potentially harm the mother or fetus. Similarly, how often a women receives prenatal care is important, too, because periodic monitoring (with frequency determined by need) is essential for ensuring a good pregnancy outcome. Because many insurance plans do not cover prenatal care and because Medicaid does not reimburse for these services at levels high enough to encourage all providers to participate, income is an important barrier to access. However, securing direct evidence of the link between income and access to care on a routine basis is difficult since income information is not reported on birth certificates. The Health Resources and Services Administration is testing the feasibility of combining the information provided on birth certificates with income data by zip code from the Census Bureau to estimate the income levels of women who use varying quantities of prenatal care services. Preliminary results from a pilot study in New York City indicate that living in lower-income neighborhoods is correlated with less use of prenatal care (Zeitel et al., 1991). Several factors may affect the accuracy and usefulness of various measures of prenatal care. For example, none of the several measurement methodologies in widespread use defines in any precise way the components of a typical prenatal care visit (Institute of Medicine, 1988). In addition, several measurement methods rely for data collection on the memories of pregnant women or on their medical records, both of which can be faulty. Even the accuracy of birth certificates, used by the NCHS to generate most of the available information about prenatal care, has been called into question (National Center for Health Statistics, 1983; see also NCHS, 1980a).

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Access to Health Care in America In addition to these generic problems, each of the three most common approaches to assessing the use of prenatal care has specific limitations. Studies that simply count the number of prenatal care visits tell nothing about the distribution of those visits throughout the pregnancy. Analyses that focus on when prenatal care was begun fail to reveal whether that care had any continuity. Moreover, indices of prenatal care that combine the number of visits and timing of prenatal care with other variables (in the case of the modified Kessner index, for example, with gestational age) can be confounded by incomplete or missing data for one or more variables (Alexander et al., 1991). In short, no currently available method for measuring the use of prenatal care services is without its drawbacks. Trends in the Data The committee decided that the most valuable overall indicator of utilization is the percentage of women receiving adequate prenatal care as measured by the modified Kessner index. Although it recognizes the problems with the Kessner index, the committee believes that by combining early initiation of care with the number of visits (adjusted for gestation), the index provides the most appropriate standard of the measures currently and widely available. Table 3-2 displays the percent distribution of births by adequacy of care for 1986–1988 as measured by the modified Kessner index. For all races, slightly less than 70 percent of all women received adequate prenatal care in each of the three years. In each year nearly three-quarters of white women but only one-half of black women received adequate care. Comparable national data from earlier years are not available. Although the relative differences are small, improvement was greater for whites (0.9 percent) than for blacks (0.1 percent)—a trend that should be watched closely in future years. The NCHS plans to update the Kessner index annually. Beginning in 1989, all states are reporting the data necessary to construct the index. Trend data are available to indicate the percentage of women who begin prenatal care in the first trimester, a key component of the modified Kessner Index. As Table 3-3 indicates, approximately 75 percent of all U.S. women begin prenatal care at that time. The comparable figure for white women is approximately 80 percent and for black women 60 percent. The table also shows that the percentage of women receiving early care increased steadily during the 1970s (from 67.9 percent for all races in 1970 to 75.9 percent in 1979) but remained static between 1980 and 1988. As the final column in the table indicates, the gap in the use of early prenatal services between white and black women, after decreasing rapidly during the 1970s, has worsened slightly since 1980. Table 3-4 indicates the percentage of women, by race/ethnicity of the

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Access to Health Care in America TABLE 3-2 Percent Distribution of U.S. Births by Adequacy of Care (Modified Kessner Index), 1986–1988 Care Level All Races Black White Adequate       1986 68.4 50.6 72.6 1987 68.7 50.7 73.2 1988 68.9 50.7 73.5 Intermediate       1986 23.6 34.2 21.0 1987 23.2 33.6 20.6 1988 23.1 33.8 20.4 Inadequate       1986 8.0 15.3 6.3 1987 8.1 15.7 6.2 1988 8.0 15.5 6.1   SOURCE: National Center for Health Statistics, based on data from 49 reporting states and the District of Columbia. mother, seeking early prenatal care. The percentage for all races for 1988 was 75.9; however, the percentages by ethnic group varied from less than 60 percent for Native Americans and Mexican Americans and 61.1 percent for blacks to 82.4 percent for Chinese, 83.4 percent for Cubans, and 86.3 percent for Japanese. Less than 65 percent of Puerto Rican and Central and South American women living in the United States had early prenatal visits in 1988. The wide variations by race and ethnicity have been constant over the past decade (U.S. Public Health Service, 1991). The existence of a broad range of barriers to the use of prenatal care services has been extensively documented. Indeed, several years ago IOM prepared a review of much of the relevant literature, grouping the barriers into four categories: (1) financial (including insurance or lack thereof, eligibility for insurance coverage, scope and depth of insurance coverage, and Medicaid coverage); (2) inadequate capacity of the personal health care system (including not only private physicians but also factors influencing such organized health care settings as hospital outpatient departments and community and migrant health centers); (3) organizational aspects of prenatal services (including links among various programs that furnish prenatal care); and (4) cultural and personal factors (including care-seeking behavior, views about the importance of prenatal care, and drug and alcohol abuse) (Institute of Medicine, 1988). Measuring the organizational factors that influence the quality and content

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Access to Health Care in America TABLE 3-3 Percentage of U.S. Women Receiving Early Prenatal Care,a by Race, 1970–1988       Nonwhite   Ratio Year All Races White Black Total White/Black 1970 67.9 72.4 44.3 46.0 1.63 1971 68.6 73.0 44.3 48.1 1.65 1972 69.4 73.6 49.0 50.6 1.50 1973 70.8 74.9 51.4 52.9 1.46 1974 72.1 75.9 53.9 55.3 1.41 1975 72.3 75.9 55.8 57.0 1.36 1976 73.5 76.8 57.7 58.8 1.33 1977 74.1 77.3 59.0 60.1 1.31 1978 74.9 78.2 60.2 61.4 1.30 1979 75.9 79.1 61.6 62.9 1.28 1980 76.3 79.3 62.7 63.8 1.26 1981 76.3 79.4 62.4 63.8 1.27 1982 76.1 79.3 61.5 63.2 1.29 1983 76.2 79.4 61.5 63.4 1.29 1984 76.5 79.6 62.2 64.1 1.28 1985 76.2 79.4 61.8 63.7 1.28 1986 75.9 79.2 61.6 63.7 1.29 1987 76.0 79.4 61.2 63.4 1.30 1988 75.9 79.4 61.1 63.6 1.30 a Early prenatal care is defined as care beginning in the first trimester. SOURCE: Published and unpublished data from the National Center for Health Statistics as reported in Children's Defense Fund (Rosenbaum et al., 1991); additional calculations by the Institute of Medicine. of prenatal care is clearly an important task, and it remains a major challenge for researchers (Culpepper, 1991). For example, where women first receive prenatal care varies according to race. Data from 1982 and 1983, collected during cycle III of the National Survey of Family Growth, show that 80 percent of white women who began prenatal care during the first trimester visited a personal, private physician (as opposed to a hospital, health department, or clinic), whereas only 48 percent of black women receiving early prenatal care did so (National Center for Health Statistics, 1988). Further work is needed to sort out the implications of these and other organizational differences—both in terms of positive and negative consequences. Recommendations Improved Data from the Revised Standard Birth Certificate and the 1988 National Maternal and Infant Health Survey. The standard birth certificate

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Access to Health Care in America TABLE 3-4 Percentage of Women Receiving Early Prenatal Care,a by Race/Ethnicity, 1988 Race/Ethnicity Percentage All races 75.9b American Indian 58.1 Black 61.1b Central/South American 63.1 Chinese 82.4 Cuban 83.4 Filipino 78.4 Japanese 86.3 Mexican American 58.3 Puerto Rican 63.3 White 79.4b a Early prenatal care is defined as care beginning in the first trimester. b Data received directly from the National Center for Health Statistics' Vital Statistics System. SOURCE: National Center for Health Statistics (1990c). has been revised to include more information on risk factors that affect pregnancy. The form now allows check-box entries for each of 16 medical risk factors. More research and analysis are needed to relate prenatal care and birth outcomes to these risk factors. The 1988 National Maternal and Infant Health Survey (NMIHS; National Center for Health Statistics, 1991) obtained information from mothers, hospitals, and providers on pregnancies, pregnancy outcomes, and early infant health. In addition, a longitudinal follow-up study was begun in 1990. The study will provide more information on the dynamics of prenatal care; child development; and the effects of low birthweight, child nutrition, and exposure to environmental hazards. The committee supports these efforts and recommends that NCHS expedite the analysis and release of these data. In addition, the committee recommends that research be undertaken to determine the accuracy of birth certificate data through a comparison of those data with data from the NMIHS. Finally, given the importance of financial barriers to access to prenatal care, the committee recommends that the NCHS consider further revision of the birth certificate to include income class and insurance information. Content and Timing of Prenatal Services. The committee recommends the continuation of research into the measurement of the content of prenatal care, especially for high-risk pregnancies. This research is likely to improve our understanding of the relationship between prenatal care and successful

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Access to Health Care in America birth outcomes. In this regard the committee supports the National Fetal and Infant Mortality Review Program established by the American College of Obstetrics and Gynecology. This program is designed to assist communities in identifying specific causes of infant and fetal mortality and the barriers that need to be addressed. Community-based studies will also help clarify how the constellation of available resources and the way they are organized affect outcomes. Financial Barriers to Access. The committee recommends the continuation of efforts to develop a better understanding of the relationship between income and access to prenatal care. The committee was encouraged by the results of a pilot project in New York City that linked birth certificate data with Census Bureau income data by zip code. States should subscribe to the long-term objective of computerizing their birth and death records in ways that will promote small-area analyses and needs assessment—not only in terms of income but also in relation to other characteristics of local communities. Improved Measurement of Prenatal Services. Although the committee has chosen to use the modified Kessner index as a measure of the adequacy of prenatal care, this method is not without its problems. Federal agencies and the states need to continue to develop better indices of adequate prenatal care. The federal Bureau of Maternal and Child Health, for example, has supported state efforts to develop a common outcome-oriented minimum data set and a standard definition of adequate prenatal care. Efforts should be made to develop an index that measures the timing, sensitivity, content, and quality of prenatal care and that accounts for the effects of various risk factors in determining adequacy. Outcome Indicator: Infant Mortality Infant mortality refers to children who die before their first birthday. Subcomponent measures of infant mortality are derived by dividing the first year after birth into two stages: neonatal (28 days old or younger) and postneonatal (between 28 days and 1 year of age). Each measure may provide potentially useful information about barriers to health care access. Dividing the first year of life into two parts allows identification of the most appropriate health interventions for specific infant age groups. Reducing neonatal mortality requires not only that steps be taken during pregnancy to increase birthweight but also that intrapartum and newborn care be improved. To achieved the latter, reorganized perinatal services have been put in place. Interventions intended to reduce postneonatal mortality must focus on improving well- and sick-child care and on intensive follow-up of high-risk infants (Centers for Disease Control, 1989b).

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Access to Health Care in America to be insured (38.6 percent of men had coverage). Only 10 percent of those with incomes under $10,000 had dental insurance, compared with 56.6 percent of those with incomes above $35,000. People with more than a high school education were almost three times as likely as those with less than nine years of education to have dental insurance (44.6 versus 15.3 percent, respectively). Those in good to excellent health were nearly twice as likely as those in fair or poor health to have dental insurance (41.5 versus 23.4 percent, respectively). In 1989 those with dental insurance made an average of about one more visit annually to the dentist than those without insurance (2.7 visits compared with 1.7 visits; Table 3-28). This same insurance-related differential was apparent for both blacks and whites. Regardless of insurance status, whites (2.8 visits by insured, 1.8 visits by uninsured) made more visits than blacks (1.7 visits by insured, 0.9 visits by uninsured). A factor of concern is that the use of dental services among blacks appeared to decline between 1986 and 1989. At each income level, those with insurance made more visits than those without insurance. It is not clear why those with insurance and incomes under $10,000 had such a high number of visits; it may relate to the fact that only a small percentage (10 percent) of this group has insurance. The committee's analysis of hospital discharge data from 11 states revealed that residents in low-income zip codes are almost three times (2.86) as likely to be admitted to hospitals for dental conditions as those from high-income zip codes. Hospital admission for the specific set of ICD-9 TABLE 3-28 Annual Dental Visits, by Dental Insurance Status and Selected Characteristics, 1986 and 1989   Private Insurance Uncovered Characteristic 1986 1989 1986 1989 Total 2.6 2.7 1.7 1.7 Race         Black 2.0 1.7 1.1 0.9 White 2.7 2.8 1.8 1.8 Family income         Less than $10,000 2.9 2.1 1.2 1.2 $10,000-$19,999 1.9 2.1 1.5 1.3 $20,000-$34,999 2.6 2.3 2.1 1.8 $35,000 or more 2.9 3.1 2.4 2.5   SOURCE: Unpublished data from the National Health Interview Surveys, National Center for Health Statistics, 1986 and 1989.

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Access to Health Care in America codes selected by the committee is indicative of advanced dental disease that may be caused by lack of adequate ambulatory dental care. Because admission rates for dental problems are fairly low (less than 0.1 per 1,000 population for the 11 states studied), by itself the measure has limited utility as an outcome indicator. Two recent studies have shown that Medicaid coverage of dental services appears to impose its own set of access problems on low-income patients. In a review of the Medicaid policies of seven states, the Office of Technology Assessment (1990) found significant differences in the dental services offered. To varying degrees, each state program failed to adequately cover a number of basic dental services. Several specific barriers to dental services were identified, including low Medicaid reimbursement rates, which resulted in inadequate treatment for patients or discouraged dentists from participating in the program; insufficient subsidization of patient transportation costs to the dentist's office; and Medicaid recipients' own lack of awareness of their dental benefits, failure to use their benefits even when aware of them, and negative perceptions about dentistry. A study of California's Medi-Cal program (Damiano et al., 1990) found a similar set of problems. Medi-Cal reimbursement rates for dental services are significantly lower than the fees charged by private practitioners, which discourages many dentists from treating those covered by the program. Only about 15 percent of all general practice and pediatric dentists in the state accept new Medi-Cal patients; by geographic area, 28 of California's 58 counties had no dentists willing to accept Medi-Cal patients. Overall, the 1,800 dentists in Medi-Cal's dental referral program were responsible for meeting the needs of about 3 million eligible patients across the state. Recommendations NHIS Dental Supplements. Questions in future NHIS dental supplements should gather information not only about private insurance coverage but also about publicly funded coverage, such as that provided by Medicaid, Medicare (for oral surgery), the Department of Veterans Affairs, and the military (for dependents). The specific content of care received by patients, including preventive and routine checkups, restorative treatment, extractions, and full or partial dentures, should be captured by the survey. NHIS questions should also probe in greater detail the factors, including cost, that prevent patients from visiting the dentist. Research Studies. The committee recommends that research be conducted to determine trends in the effect of private insurance on access to various types of dental services.

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Access to Health Care in America Outcome Indicator: Avoidable Hospitalization for Acute Conditions For the purposes of this indicator, hospitalizations are hospital admissions for conditions related to an acute episode of disease. Avoidable hospitalizations are those that probably would not have occurred had the patient received appropriate and timely outpatient (ambulatory) medical care. People who are in good to excellent health—the population of interest in this objective—may seek medical attention for any number of reasons. (See the discussion for the indicator ''Routine Physician Contacts" above.) The personal health care system in some cases provides only symptomatic relief to patients for conditions that would resolve independent of any medical intervention. In other situations, however, symptoms that are not addressed in a timely fashion can evolve into acute medical problems requiring hospitalization. For example, a child with pain and fever may be treated by a parent with an over-the-counter cold medication. If the child is from a family with no regular source of medical care and if the symptoms become severe enough, a visit to the emergency room may become necessary. An emergency room physician, unaware that there has been a history of these infections, may release the child to his or her parents. At home the child may get progressively worse and eventually develop severe otitis media requiring hospitalization. There are many other examples of potential problems faced by people without a regular source of medical care. Someone who experiences frequent urination, a burning sensation, or intermittent pain upon urination, indicating a relatively simple-to-treat urinary tract infection, may, if untreated, be at risk for developing a severe kidney infection. A persistent cough can signal any number of conditions, including tuberculosis or pneumonia. Untreated diarrhea can evolve into severe gastroenteritis. For the significant segment of the population with no or inadequate health insurance, or who for other reasons have no regular source of medical care, hospital emergency rooms are increasingly being used as walk-in clinics for all manner of health complaints. Although few would maintain that the hospital emergency department is an optimum site for primary care, in the absence of a well-organized system of ambulatory care for those unable to afford private medical care, it is one of the only options. Unfortunately, especially in inner-city hospitals, inpatient bed space is limited. Many emergency rooms overflow not only with patients waiting to be seen by a doctor but also with patients who are already evaluated and are waiting to be assigned a hospital bed. Some evidence suggests that a significant proportion of emergency room patients with serious medical conditions leave the hospital without ever being seen. One of two recent studies found that

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Access to Health Care in America 11 percent of such patients ended up being hospitalized within the next week (Baker et al., 1991). In the second study, only 4 percent ended up being hospitalized but 27 percent returned to an emergency room (Bindman et al., 1991). Measuring the Indicator The committee used the same approach to measure avoidable hospitalization for acute conditions that it used for chronic disease conditions (see Objective 3). The only difference is that a different set of ICD-9 diagnosis codes will be highlighted in the analysis. The committee chose to examine acute-illness-related data for diagnoses that, with timely and effective outpatient care, normally would not result in a hospital admission. Mild cases of bacterial pneumonia, cellulitis, urinary tract infections, ENT (ear, nose, and throat) infections, and precursor infections leading to pelvic inflammatory disease can often be managed with antibiotics in outpatient settings, preventing the disease from becoming more severe. In selecting specific ICD-9 codes to represent ambulatory-care-sensitive conditions, an effort was made to screen out, where possible, those admissions that would cloud interpretation of the phenomenon of interest: timely and appropriate outpatient care. For example, cases of cellulitis in which a surgical procedure was performed are excluded, because they may be repeat hospitalizations for plastic surgery procedures or trauma cases. Admissions from nursing facilities were also excluded, since these cases have been under at least nominal medical care. The committee recognizes that the causes behind many hospital admissions for acute conditions are more complex than a delayed outpatient visit. Higher rates of admissions from low-income neighborhoods may be due to lack of health knowledge, comorbidities, or differences in prevalence arising from environmental and social factors related to poverty—all of which can interact with financial barriers to delay care. However, differences in the prevalence of various diseases among the poor, while explaining some portion of admission rate differentials, do not obviate conclusions about the presence of access problems. To counterbalance social factors, equity of access to appropriate care may require more or different types of services for some populations. For instance, these services might include nutrition education for new mothers to lower rates of gastrointestinal diseases, screening young women for venereal disease to lower their rates of pelvic inflammatory disease, or addiction services for alcoholics who are at risk of various medical complications. As in the previous indicators that use hospital discharge data, this indicator is measured by the ratio of hospital admissions from low-income zip codes to admissions from high-income zip codes. High-income areas are

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Access to Health Care in America Table 3-29 Ambulatory-Care-Sensitive Conditions: Acute Disease, 1988 Admission Rates by Zip Code Income Groupings, Nonelderly Population, 11 States Condition Low-Income Admissions/1,000 Population High-Income Admissions/1,000 Population Ratio, Low/High Income Bacterial pneumonia 4.39 0.81 5.42 Cellulitis 2.11 0.42 5.02 Dehydration as primary diagnosis 0.59 0.28 2.11 Gastroenteritis 1.30 0.68 1.91 Kidney/urinary infection 1.28 0.46 2.78 Severe ear, nose, and throat infections 0.82 0.24 3.42 Skin graft with cellulitis 0.46 0.08 5.75 Total 10.95 2.97 3.69 Source: Joint data and analysis by the Codman Research Group, the Ambulatory Care Access Group (United Hospital Fund of New York), and the IOM Access Monitoring Committee. those in which 10 percent or less of families have incomes below $15,000. In low-income areas, 60 percent or more of the families have incomes of $15,000 or less. Again, the focus is on those under 65 years of age. Trends in the Data Table 3-29 highlights a number of ambulatory-care-sensitive conditions relevant to the present discussion of hospitalization for acute disease that might have been avoided with timely and appropriate care. For most of the diagnoses in the table, the rates of hospital admissions from low-income zip codes were two to five times higher than rates from high-income zip codes. The overall average ratio was 3.69. Recommendation Many patients seen in a hospital emergency room may be unable or unwilling to do what is necessary to recuperate at home from a serious illness. In many cases, such patients have poor social support networks, may live in homes that are overcrowded or without heat, or may be unable

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Access to Health Care in America to afford the necessities of life, such as food. Relatives of such a patient may have low-income jobs that make it difficult for them to stay home and provide needed care for the sick person or to pay for needed medications. For these and other reasons, physicians may be inclined to hospitalize low-income patients more frequently than high-income ones. Current data on hospitalization do not take into account the possibility that physicians may be using different standards to admit patients (Billings et al., 1991). However, Billings' analysis of New York City data did indicate that the severity of illness for patients from the poorest zip codes was equivalent to that of patients from the highest-income zip code. As was true for chronic-disease-related conditions, the committee believes that more detailed studies of patients and of admitting physicians are needed. These studies should sort out the relative contributions of the various factors that lead to the hospitalization of people without a source of regular medical care. Use of hospital discharge data will be enhanced to the extent that specific diagnoses can be explored in greater depth to determine their utility as indicators of access problems. REFERENCES Alexander, G. R., Tompkins, M. E., Peterson, D. J., and Weiss, J. 1991. Source of bias in prenatal care utilization indices: Implications for evaluating the Medicaid expansion. American Journal of Public Health 81:1013–1016. American Cancer Society. 1989. Cancer Statistics, 1989. CA: A Cancer Journal for Clinicians 39:3–20. American College of Obstetricians and Gynecologists, Committee on Professional Standards. 1989. Standards for Obstetric-Gynecological Services, Seventh edition. Washington, D.C.: ACOG. Baker, D. W., Stevens, C. D., and Brook, R. H. 1991. Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences. Journal of the American Medical Association 266:1085–1090. Behrman, R. E. 1987. Premature births among back women. New England Journal of Medicine 317:763–765. Bild, D., Geiss, L. S., Teutsch, S. M., et al. 1988. Sentinel health events surveillance in diabetes. Journal of Clinical Epidemiology 41:999–1006. Billings, J., Zeitel, L., Lukomnik, J., et al. 1991. Analysis of Variation in Hospital Admission Rates Associated with Area Income in New York City. New York: Ambulatory Care Access Project/United Hospital Fund of New York. Bindman, A. B., Grumbach, K., Keane, D., Rauch, L., and Luce, J. M. 1991. Consequences of queuing for care at a public hospital emergency department. Journal of the American Medical Association 266:1091–1096. Blendon, R. J., Aiken, L. H., Freeman, H. E., and Corey, C. R. 1989. Access to medical care for black and white Americans. Journal of the American Medical Association 261:278-281. Bloom, B. 1988. Health Insurance and Medical Care: Health of our Nation's Children, United States. Advance Data No. 188. Hyattsville, Md.: National Center for Health Statistics. Boutwell, R. C., and Mitchell, J. B. 1991. Diffusion of new technologies in the Medicare

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