Utilization of physician services among West Texas elders in the context of rural residence: A multi-level analysis

Access to physician services is important for the receipt of ambulatory treatment, preventive care, and early diagnosis of disease. Populations that are at risk for not receiving physician services should be a focus of health system planners. Access barriers to physician services may be due to individual characteristics or characteristics of the environment in which health care is being delivered.

The primary purpose of this study was to determine which factors of the individual and the environment inhibit contact with a physician using multilevel analysis. The two levels of measurement are the individual and the county environment. Individual characteristics examined include demographics, socioeconomic status, insurance status, health status, health beliefs, and social involvement. Environmental characteristics measured on the county level include population per direct patient care physician, population density, per capita income, percent of population below the poverty level, and metropolitan status. Access to physician services was evaluated among an elderly cohort in West Texas. Data were collected by telephone interview from over 5,000 non-cognitively impaired individuals over 65.

Having visited a physician in the six months preceding the interview was the dependent variable in a multilevel logistic model including predisposing, enabling, need, and environmental characteristics. Individual variability accounted for far more of the variation in physician contact than did variation across counties. After controlling for health status, individual characteristics that were significantly (p<0.05) associated with access problems included skepticism about medical care, religiousness, level of education, income, and type of insurance. Only 7% of the variation in physician contact was due to variation across counties. However, the characteristics of provider supply, metropolitan status, and economic status of the county explained all of the between county variation. The importance of predisposing, enabling, and environmental characteristics in predicting contact with physician services after controlling for health status indicates inequitable access in the elderly population with the potential to be corrected with policy interventions. More needs to be done to enhance our understanding of individual care seeking behavior. The use of modeling techniques that account for the context in which the choice to seek care is being made are necessary to clarify whether individual or environmental factors are affecting access.