Cognitive appraisals of specialty mental health services and their relation to mental health service utilization in the rural population

Abstract Purpose: Rural individuals utilize specialty mental health services (eg, psychiatrists, psychologists, counselors, and social workers) at lower rates than their urban counterparts. This study explores whether cognitive appraisals (ie, individual perceptions of need for services, outcome expectancies, and value of a positive therapeutic outcome) of help‐seeking for depression symptoms are related to the utilization of specialty mental health services in a rural sample. Methods: Demographic and environmental characteristics, cultural barriers, cognitive appraisals, and depression symptoms were assessed in one model predicting specialty mental health service utilization (MHSU) in a rural sample. Three hypotheses were proposed: (1) a higher number of environmental barriers (eg, lack of insurance or transportation) would predict lower specialty mental health service utilization; (2) an increase in cultural barriers (stigma, stoicism, and lack of anonymity) would predict lower specialty mental health utilization; and (3) higher cognitive appraisals of mental health services would predict specialty mental health care utilization beyond the predictive capacities of psychiatric symptoms, demographic variables, environmental barriers, and cultural barriers. Findings: Current depression symptoms significantly predicted lifetime specialty mental health service utilization. Hypotheses 1 and 2 were not supported: more environmental barriers predicted higher levels of specialty MHSU while cultural barriers did not predict specialty mental health service utilization. Hypothesis 3 was supported: cognitive appraisals significantly predicted specialty mental health service utilization. Conclusions: It will be important to target perceptions and attitudes about mental health services to reduce disparities in specialty MHSU for the rural population.     

Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status

PURPOSE Long-term shifts in specialty choice and health workforce policy have raised concern about the future of primary care in the United States. The objective of this study was to examine current use of primary and specialty care across the US population for policy-relevant subgroups, such as disadvantaged populations and persons with chronic illness.METHODS Data from the Medical Expenditure Panel Survey from 2004 were analyzed using a probability sample patients or other participants from the noninstitutionalized US population in 2004 (N = 34,403). The main and secondary outcome measures were the estimates of the proportion of Americans who accessed different types of primary care and specialty physicians and midlevel practitioners, as well as the fraction of ambulatory visits accounted for by the different clinician types. Data were disaggregated by income, health insurance status, race/ethnicity, rural or urban residence, and presence of 5 common chronic diseases.RESULTS Family physicians were the most common clinician type accessed by adults, seniors, and reproductive-age women, and they were second to pediatricians for children. Disadvantaged adults with 3 markers of disadvantage (poverty, disadvantaged minority, uninsured) received 45.6% (95% CI, 40.4%–50.7%) of their ambulatory visits from family physicians vs 30.5% (95% CI, 30.0%–32.1%) for adults with no markers. For children with 3 vs 0 markers of disadvantage, the proportion of visits from family physicians roughly doubled from 16.5% (95% CI, 14.4%–18.6%) to 30.1% (95% CI, 18.8%–41.2%). Family physicians constitute the only clinician group that does not show income disparities in access. Multivariate analyses show that patterns of access to family physicians and nurse-practitioners are more equitable than for other clinician types.CONCLUSIONS: Primary care clinicians, especially family physicians, deliver a disproportionate share of ambulatory care to disadvantaged populations. A diminished primary care workforce will leave considerable gaps in US health care equity. Health care workforce policy should reflect this important population-level function of primary care.     

Disparities in primary care for vulnerable children: the influence of multiple risk factors

OBJECTIVES: To analyze vulnerability as a profile of multiple risk factors for poor pediatric care based on race/ethnicity, poverty status, parent education, insurance, and language. Profiles are used to examine disparities in child/adolescent health status and primary care experience. DATA SOURCES: Cross-sectional data on 19,485 children/adolescents 0-19 years of age from the 2001 California Health Interview Survey. STUDY DESIGN: Multiple logistic regression models are used to examine risk profiles in relation to health status and three aspects of primary care: access (physician and dental visit; access surety), continuity (regular source of care), and comprehensiveness (i.e., health promotion counseling). PRINCIPAL FINDINGS: About 43 percent of (or 4.4 million) children in California have two or more risk factors (RF). Controlling for age and gender, more RFs is associated with poorer health status (i.e. percent reporting "excellent/very good" health: no RFs=81 percent, 1=71 percent, 2=57 percent, 3=45 percent, 4=35 percent, 5=28 percent, all p<.001). Controlling for health status, higher risk profiles is associated with poorer primary care access and continuity, but greater comprehensiveness of care. For example, higher risk profile children are less likely to have a regular source of care: one RF (prevalence ratio [PR]=0.92, confidence interval [CI]: 0.86-0.98), two (PR=0.77, CI: 0.69-0.84), three (PR=0.55, CI: 0.46-0.65), and four or more (PR=0.31, CI: 0.22-0.44), all p<.001. CONCLUSIONS: This study demonstrates a dose-response relationship of higher risk profiles with poorer child health status, access to, and continuity of primary care. Having gained access, however, adolescents with higher risk profiles are more likely to receive health promotion counseling. Higher profiles appear to be associated with greater barriers to accessing primary care for children in "fair or poor" health, suggesting that vulnerable children who have the greatest health care needs also have the greatest difficulty obtaining primary care.     

State Medicaid fees and access to primary care physicians

Medicaid and uninsured patients are disadvantaged in access to care and are disproportionately Black and Hispanic. Using a national audit of primary care physicians, we examine the relationship between state Medicaid fees for primary care services and access for Medicaid, Medicare, uninsured, and privately insured patients who differ by race/ethnicity and sex. We found that states with higher Medicaid fees had higher probabilities of appointment offers and shorter wait times for Medicaid patients, and lower probabilities of appointment offers and longer wait times for uninsured patients. Appointment offers and wait times for Medicare and privately insured patients were unaffected by Medicaid fees. At mean state Medicaid fees, our analysis predicts a 27‐percentage‐point disadvantage for Medicaid versus Medicare in appointment offers. This decreases to 6 percentage points when Medicaid and Medicare fees are equal, suggesting that permanent fee parity with Medicare could eliminate most of the disparity in appointment offers for Medicaid patients. The predicted decrease in the disparity is smaller for Black and Hispanic patients than for White patients. Our research highlights the importance of considering the effects of policy on nontarget patient groups, and the consequences of seemingly race‐neutral policies on racial/ethnic and sex‐based disparities.     

GP Clinic: promoting access to primary health care for mental health service clients

Objective: To evaluate an innovative rural service offering comprehensive primary health care for mental health service clients. Design: A formative evaluation using mixed methods. Setting: A rural NSW community. Participants: Fifteen health care providers and 120 adult clients. Intervention: A monthly clinic held in a general practice to provide primary health care for clients of the community mental health team. Main outcome measures: Client utilisation and clinic activity data. Provider views of service effectiveness, possible improvements and sustainability. Results: The GP Clinic has operated successfully for 2.5 years without access block. Some 52% of clients had no physical illness and 82% were referred to other health and community services. In total, 40% continued to attend the clinic while 32% went on to consult a GP independently. Client access to care improved as did collaboration between the community mental health team and primary care providers. Conclusion: The GP Clinic is a straightforward and flexible service model that could be used more widely.     

Patient-reported care coordination: associations with primary care continuity and specialty care use

PURPOSE Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use.METHODS We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use.RESULTS Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77).CONCLUSIONS High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.     

Primary sources of health care among LGBTQ+ veterans: Findings from the Behavioral Risk Factor Surveillance System

Objective

This study examined the primary source of health care between veterans with lesbian, gay, bisexual, queer and similar identities (LGBTQ+) and non-LGBTQ+ veterans.

Data Sources and Study Setting

Veterans (N = 20,497) from 17 states who completed the CDC's Behavioral Risk Factor Surveillance System from 2016 to 2020, including the Sexual Orientation and Gender Identity and Health Care Access modules.

Study Design

We used survey-weighted multiple logistic regression to estimate average marginal effects of the prevalence of utilization of Veteran's Health Administration (VHA)/military health care reported between LGBTQ+ and non-LGBTQ+ veterans. Prevalence estimates were adjusted for age group, sex, race and ethnicity, marital status, educational attainment, employment status, survey year, and US state.

Data Collection Methods

Study data were gathered via computer-assisted telephone interviews with probability-based samples of adults aged 18 and over. Data are publicly available.

Principal Findings

Overall, there was not a statistically significant difference in estimated adjusted prevalence of primary use of VHA/military health care between LGBTQ+ and non-LGBTQ+ veterans (20% vs. 23%, respectively, p = 0.13). When examined by age group, LGBTQ+ veterans aged 34 and younger were significantly less likely to report primary use of VHA/military health care compared to non-LGBTQ+ veterans (25% vs. 44%, respectively; p = 0.009). Similarly, in sex-stratified analyses, fewer female LGBTQ+ veterans than female non-LGBTQ+ veterans reported VHA/military health care as their primary source of care (13% vs. 29%, respectively, p = 0.003). Implications and limitations to these findings are discussed.

Conclusions

Female and younger LGBTQ+ veterans appear far less likely to use VHA/military for health care compared to their cisgender, heterosexual peers; however, because of small sample sizes, estimates may be imprecise. Future research should corroborate these findings and identify potential reasons for these disparities.     

Virtual primary care in high-income countries during the COVID-19 pandemic: Policy responses and lessons for the future

BackgroundTelemedicine, once defined merely as the treatment of certain conditions remotely, has now often been supplanted in use by broader terms such as ‘virtual care’, in recognition of its increasing capability to deliver a diverse range of healthcare services from afar. With the unexpected onset of COVID-19, virtual care (e.g. telephone, video, online) has become essential to facilitating the continuation of primary care globally. Over several short weeks, existing healthcare policies have adapted quickly and empowered clinicians to use digital means to fulfil a wide range of clinical responsibilities, which until then have required face-to-face consultations.ObjectivesThis paper aims to explore the virtual care policies and guidance material published during the initial months of the pandemic and examine their potential limitations and impact on transforming the delivery of primary care in high-income countries.MethodsA rapid review of publicly available national policies guiding the use of virtual care in General Practice was conducted. Documents were included if issued in the first six months of the pandemic (March to August of 2020) and focussed primarily on high-income countries. Documents must have been issued by a national health authority, accreditation body, or professional organisation, and directly refer to the delivery of primary care.ResultsWe extracted six areas of relevance: primary care transformation during COVID-19, the continued delivery of preventative care, the delivery of acute care, remote triaging, funding & reimbursement, and security standards.ConclusionVirtual care use in primary care saw a transformative change during the pandemic. However, despite the advances in the various governmental guidance offered, much work remains in addressing the shortcomings exposed during COVID-19 and strengthening viable policies to better incorporate novel technologies into the modern primary care clinical environment.     

Latinos' health care access: financial and cultural barriers

This study aimed at investigating how income, culture, and language affect health care access. Data from a structured questionnaire administered to a random sample of 206 Latinos was analyzed using multivariate logistic regression. Qualitative data served to explain quantitative results. Point estimates for various access measures were similar to national data. In multivariate logistic regression, income and education determined having health insurance (OR 6.8 and 7.4; 95% CI 2.7-17.3 and 2.9-19.0, respectively). Time in the U.S. and health insurance determined having a regular source of care (OR 4.6 and 5.8; 95% CI 1.7-12.8 and 2.1-16.0, respectively). Having a source of care and being female determined visit to the doctor in the past year (OR 6.14 and 6.73; 95% CI 2.3-16.5 and 2.4-19.3, respectively). Language and culture showed no statistically significant effect on access measures, but qualitative data showed they were related to health care barriers.     

Improving health equity through health care systems research

Objective

To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes.

Data Sources and Study Setting

This project was conducted as a component of the Agency for Healthcare Research and Quality's (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government.

Study Design

Expert group consensus, informed by stakeholder engagement and targeted evidence review.

Data Collection/Extraction Methods

Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQ's 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors' consensus.

Principal Findings

Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines.

Conclusions

As the nation's primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.     

Improving the evidence‐base for access to primary health care in Canterbury: a panel study

Objective : Despite many reforms and initiatives, inequities in access to primary health care remain. However, the concept of ‘access’ and its measurement is complex. This paper aims to provide estimates of general practice visit frequencies for ‘attenders’ (those who seek consultation) and the proportion of ‘non‐attenders’ (those who never seek consultation) of primary health care services. Methods : A panel study of people enrolled within a large primary health care organisation of affiliated general practices. Standard and zero‐inflated regression models were assessed. Results : 980,918 visits were made by 388,424 people, averaging 2.64 visits/person/year. The zero‐inflated negative binomial model was superior, and significant age, gender and ethnic differences were observed in attender and non‐attender profiles. More Asian (21.0%), Pacific (19.6%) and Māori (17.1%) people were non‐attenders than European/Other (9.0%) people. Among attenders, males, Asian and Pacific people, and young to middle‐aged adults, generally had relatively lower visit rates. Conclusions : Interpretation of utilisation data must be made with caution because of two distinct characteristics: the differential rates of non‐attenders and the highly dispersed distribution of attenders. Implications : Improved understanding of differential non‐attender rates and attender visit distributions by demographic factors needs to be considered when addressing improved access to general practice services.     

Environmental factors associated with primary care access among urban older adults

Disparities in primary care access and quality impede optimal chronic illness prevention and management for older adults. Although research has shown associations between neighborhood attributes and health, little is known about how these factors - in particular, the primary care infrastructure - inform older adults' primary care use. Using geographic data on primary care physician supply and surveys from 1260 senior center attendees in New York City, we examined factors that facilitate and hinder primary care use for individuals living in service areas with different supply levels. Supply quartiles varied in primary care use (visit within the past 12 months), racial and socio-economic composition, and perceived neighborhood safety and social cohesion. Primary care use did not differ significantly after controlling for compositional factors. Individuals who used a community clinic or hospital outpatient department for most of their care were less likely to have had a primary care visit than those who used a private doctor's office. Stratified multivariate models showed that within the lowest-supply quartile, public transit users had a higher odds of primary care use than non-transit users. Moreover, a higher score on the perceived neighborhood social cohesion scale was associated with a higher odds of primary care use. Within the second-lowest quartile, nonwhites had a lower odds of primary care use compared to whites. Different patterns of disadvantage in primary care access exist that may be associated with - but not fully explained by - local primary care supply. In lower-supply areas, racial disparities and inadequate primary care infrastructure hinder access to care. However, accessibility and elder-friendliness of public transit, as well as efforts to improve social cohesion and support, may facilitate primary care access for individuals living in low-supply areas.