Determinants of medical care utilization: the impact of ecological factors.

Abstract

The location of health care facilities is an increasingly complex problem not only for the person seeking care, but for the pro? vider of services as well. Such factors as the increasing urbanization of the popula? tion with the rapid expansion of metro? politan areas and the concomitant choked and congested traffic flows combine to in? crease the importance of the location of medical services. This study is concerned with the effect of distance between patient and provider on the utilization of physicians' services in a metropolitan area. The data pre? sented bear on the effect that decentrali? zation of a medical care system has on the utilization of the services it provides. Spatial variables as factors in the utili? zation of medical services have been studied for more than 40 years.1 During this period, various measures of distance have been used to examine how an increase in distance between the patient and the provider of medical care acts as a barrier to utilization. Despite the use of different measures of distance, most studies show that the use of physicians' services tends to decrease with a corresponding increase in distance between patient and provider. For example, Jehlik and McNammara,2 in a study of rural families, report that as distance to a physician increases, overall utilization decreases and curative services tend to be used relatively more frequently than preventive care. These investigators also pointed to other factors as having an important bearing on utilization. Among these the spatial distribution of services and patients was found to be important. Ciocco and Altaian3 investigated the effect of distance on the travel of persons from rural and smaller urban places to a large metropolitan area for physicians' care. They found that distances and directions traveled depended upon the kind of ser? vices sought. The longest distance trips were made for specialists' services and shorter trips were made for the services provided by general practitioners. This tendency, in general, reflects the spatial distribution of physicians in private prac? tice in the United States. Thus, travel patterns depend, in part, on the organiza? tion of the medical care system. These studies and others have dealt with the travel patterns of populations in rural and smaller cities. However, the effect of distance on utilization in metropolitan areas is even more difficult to study than the effect of distance between fairly widely separated places. As stated by Shannon, Bashshur and Metzner,4 . . involvement in terms of effort, the distribution of effort over multiple purposes, choice between al? ternatives and the ease of transportation James E. Weiss, Ph.D. is Director, Center for Population Research and Census, Portland State University, Oregon. Merwyn R. Greenlick, Ph.D. is Director of Medi? cal Care Research, Health Services Research Center, Kaiser Foundation Hospitals, Portland. Joseph F. Jones, Ph.D. is Director, Center for Sociological Research, Portland State University. This paper was presented to the Medical Care Section of the American Public Health Associa? tion at the 98th annual meeting in Houston, Texas, October 26, 1970. This research was sup? ported in part by U. S. Public Health Service Grants #5 TOI HS 00023-02 and CH00235 from the National Center for Health Services Research and Development.