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Measurement: Examples
Jonathan Weiner, PhDJohns Hopkins University
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Section A
Access to Care
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Definitions of Access to Care
“The timely use of personal health services to achieve the bestpossible health outcomes” (IOM, 1993)
“Those dimensions which describe the potential and actual
entry of a given population group to the health care deliverysystem” (Aday, 1980)
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Environment
Health Care
System
External
Environ.
Population
CharacteristicsHealth Behavior Outcomes
Personal
Health
Practices
Use of
Health
Services
Predisposing
Characteristics
Enabling
Resources
Perceived
Health
Status
Evaluated
Health
Status
Consumer
Satisfaction
Home
Emerging Model
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Environment
Health care systemA.
Availability of services
1.
Volume (number of personnel, facilities)
2.
Distribution (resources per population) Health care system
B.
Organization of services
1.
Ease of entry (e.g., distance)2.
Structure (e.g., type of health insurance system)
External environment
A.
Physical (e.g., level of violence in neighborhood)B.
Economic
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Population Characteristics
Predisposing characteristicsA.
Demographics (e.g., age, sex, race)
B.
Beliefs, attitudes, knowledge
C.
Education, occupation Enabling resources
A.
Health insurance status
B.
IncomeC.
Regular source of care
D.
Residence
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Population Characteristics
NeedA.
Perceived need
1.
Perceived health status
2.
Symptoms and episodes3.
Disability
B.
Professionally evaluated need
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Health Behavior
Personal health practicesA.
Diet, exercise
B.
Self-care
Use of health servicesA.
Type of care used (e.g., MD, hospital)
B.
Location of care (e.g., clinic, office)
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Health Behavior
Use of health servicesC.
Purpose of seeking care
1.
Preventive care
2.
Illness3.
Chronic/custodial
D.
Time interval of care
1.
Contact2.
Volume (e.g., number of visits)
3.
Continuity
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Outcomes
Perceived health status−
Health as reported by the individual
Evaluated health status
−
Health as evaluated by professionals and throughsystematic assessment
Consumer satisfaction
−
Based on standardized surveys
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Concept of Mutability
If promoting access is the goal, a variable must be consideredmutable, or point to policy changes that might bring about
behavioral change
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Model Variable Degree of Mutability
Predisposing beliefs, knowledge
HIGH
Demographics
NONE
Enabling
HIGH
Personal health practices
MEDIUM
Outcomes
MEDIUM
Emerging Model
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0
5
10
15
20
25
Uninsured Private Insurance MedicaidBeneficiaries
P e r c e n
t
Percentage of people in 1989 who were in poor or fair health (by
their own report) and
who did not contact a physician. The figure, which is based on data from the 1989 National
Health Interview Survey, shows the percentages by insurance status. Adapted from IOM, Access to Health Care in America.
National Academy Press, Washington, DC (1993)
22%
9% 8%
Poor or Fair Health and No Physician Visits
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Annual Dental Care
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Insured Uninsured
Whites
Blacks V i s i t s
Number of annual dental visits by whites and blacks (according to data from the 1989
National Health Interview Survey) for those with and without private insurance. Adapted
from IOM, Access to Health Care In America. National Academy Press. Washington, D.C.,1993.
2.8
1.7 1.8
0.9
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Percentage Reporting No Visits to a Physician during One Year
Uninsured Medicaid Private/Other
1997 NMCES
1983 50 30 36
1980 NMCUES
Kaiper, 1986 43.7 21.1 24.4
Roenbach, 1985 36.3 24.8 31
1981 RWJF
Anderson, 1987 30 15 18
1984 NHIS
Rowland and Lyons, 1989 40.8 17.1 259
1986 RWJF
Freeman, 1990 44 35.7
1987–1988
Orange County Survey
Hubbell, 1989 32 11
Percentage Reporting No Visits to a Physician
Notes Available
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Section B
The Measurement and Instrument Approaches
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Identification of content areas
1.
Access
2.
Availability3.
Finances
4.
Continuity
5.
Interpersonal manner6.
Quality
900-item questionnaire field tested over four years
Summary of Ware’s Approach to Patient Satisfaction
Measurement
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Ware’s Approach
Eventual form tested in three regions Likert scale used
Acquiescence response effects (bias due to favorable
wording) Multi-item scales using factor analysis techniques
Reliability assessed by internal consistency (Cronbach’s
Alpha) and test retest
(Note—indexes did better than items on retest)
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Ware’s Approach
Validation difficult—no criteria, however, the following weredone:
1.
Content validity
2.
Factor analysis—construct validity3.
“Convergent”
validity by comparing with other
questionnaires
4.
Predictive validity was assessed by comparing the
questionnaire with other health behaviors