Racial and Socioeconomic Disparities in Access to Primary Care Among People With Chronic Conditions

Leiyu Shi; Chien-Chou Chen; Xiaoyu Nie; Jinsheng Zhu; Ruwei Hu

doi:10.3122/jabfm.2014.02.130246

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Table 1. Characteristics of Adults With Versus Without Chronic Conditions

Characteristics	Sample (n)^*	Total	Without Chronic Conditions	With Chronic Conditions
Age (years)^{^†}
18–64	18,672	82.8 (0.5)	96.3 (0.2)	69.5 (0.7)
≥64	3,594	17.2 (0.5)	3.7 (0.2)	30.6 (0.7)
Sex^{^†}
Male	10,287	48.4 (0.3)	50.1 (0.5)	46.8 (0.5)
Female	11,979	51.6 (0.3)	49.9 (0.5)	53.2 (0.5)
Race/ethnicity^{^†}
Non-Hispanic white	10,506	67.7 (1.0)	62.9 (1.3)	72.3 (0.9)
Non-Hispanic black	4,193	11.5 (0.7)	10.5 (0.7)	12.5 (0.7)
Hispanic	5,399	14.1 (0.8)	18.3 (1.0)	10.0 (0.7)
Non-Hispanic Asian	1,705	4.7 (0.4)	6.3 (0.6)	3.2 (0.4)
Other	463	2.0 (0.2)	2.0 (0.3)	2.0 (0.3)
Health insurance^{^†}
Private	12,914	67.6 (0.7)	69.5 (0.9)	65.8 (0.8)
Public	4,745	17.1 (0.5)	9.9 (0.5)	24.2 (0.7)
No insurance	4,607	15.3 (0.5)	20.7 (0.7)	10.0 (0.4)
Education^{^†}
Less than bachelor's degree	17,143	71.8 (0.6)	70 (0.8)	73.6 (0.7)
Bachelor's degree or higher	4,944	28.2 (0.6)	30 (0.8)	26.4 (0.7)
Employment status^{^†}
Unemployed	8,070	33.3 (0.6)	21.8 (0.5)	44.5 (0.8)
Employed	14,106	66.7 (0.6)	78.2 (0.5)	55.5 (0.8)
Poverty^{^‡}
Poor/negative/near poor/low income	8,753	30.3 (0.7)	29.5 (0.8)	31.2 (0.8)
Middle/high income	13,513	69.7 (0.7)	70.5 (0.8)	68.8 (0.8)
Socioeconomic status^{^†}
High	3,415	20.2 (0.5)	23.6 (0.7)	16.9 (0.6)
Above average	7,702	38.5 (0.6)	41.3 (0.7)	35.8 (0.7)
Below average	6,651	26.9 (0.5)	25.3 (0.7)	28.4 (0.6)
Low	4,234	14.4 (0.4)	9.8 (0.4)	18.9 (0.6)
Metropolitan statistical area^{^†}
No	3,138	15.8 (1.3)	13.3 (1.2)	18.1 (1.5)
Yes	19,128	84.2 (1.3)	86.7 (1.2)	81.9 (1.5)
Census region^{^†}
Northeast	3,522	18.5 (0.7)	18.5 (0.8)	18.4 (0.8)
Midwest	4,543	21.7 (0.7)	20.3 (0.8)	23.1 (0.7)
South	8,337	36.7 (0.9)	35.9 (1.1)	37.5 (1.0)
West	5,864	23.1 (0.8)	25.3 (0.9)	21.1 (0.8)
Perceived health status^{^†}
Excellent/very good/good	19,019	87.2 (0.3)	95.3 (0.2)	79.4 (0.5)
Fair/poor	3,237	12.8 (0.3)	4.7 (0.2)	20.6 (0.5)
Perceived mental health status^{^†}
Excellent/very good/good	20,462	92.6 (0.3)	96.1 (0.3)	89.2 (0.4)
Fair/poor	1,792	7.4 (0.3)	3.9 (0.3)	10.8 (0.4)
Need help with ADLs^{^†}
No	21,828	98.4 (0.1)	99.6 (0.1)	97.2 (0.2)
Yes	389	1.6 (0.1)	0.4 (0.1)	2.8 (0.2)
Need help with instrumental ADLs^{^†}
No	21,464	96.6 (0.2)	99.1 (0.1)	94.2 (0.3)
Yes	769	3.4 (0.2)	0.9 (0.1)	5.8 (0.3)

Data are % (standard error) unless otherwise indicated.
↵* Weighted N = 230,945,258.
↵† P < .001 based on χ² tests of the differences between those with and without chronic conditions.
↵‡ P < .05 based on χ² tests of the differences between those with and without chronic conditions.
ADL, activity of daily living.

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Table 2. Race/Ethnicity and Primary Care Access and Services Among Adults With Chronic Conditions

Primary Care Attributes	Sample (n)^*	Race/Ethnicity
Primary Care Attributes	Sample (n)^*	Non-Hispanic White	Non-Hispanic Black	Hispanic	Non-Hispanic Asian
Access
Have USC^{^†}	113,314,477
No	1688	11.9 (0.6)	17.9 (1.0)	21.6 (1.2)	17.4 (2.3)
Yes	8847	88.1 (0.6)	82.1 (1.0)	78.4 (1.2)	82.6 (2.3)
Type of USC^{^†}	97,611,079
Facility	4323	44.6 (1.5)	51.1 (1.5)	56.5 (2.1)	42.9 (3.7)
Person/Person in facility	4524	55.4 (1.5)	48.9 (1.5)	43.5 (2.1)	57.1 (3.7)
USC specialty	52,313,127
Primary care	4196	92.5 (0.7)	93 (1.1)	92.9 (1.6)	97.2 (1.1)
Other	328	7.5 (0.7)	7 (1.1)	7.1 (1.6)	2.8 (1.1)
USC location^{^†}	97,575,176
Office	7031	86 (0.9)	77.3 (1.4)	69 (2.1)	79.9 (2.5)
Hospital	1813	14 (0.9)	22.7 (1.4)	31 (2.1)	20.1 (2.5)
Difficulty in contacting USC by phone	94,131,693
Not very difficult	8100	95.4 (0.4)	95.0 (0.7)	94.2 (0.7)	95.3 (1.4)
Very difficult	428	4.6 (0.4)	5.0 (0.7)	5.8 (0.7)	4.7 (1.4)
USC has office ^{^†}hours nights/weekends	87,156,665
No	5032	65.7 (1.3)	65.3 (1.7)	60.1 (1.9)	47.6 (3.5)
Yes	2873	34.3 (1.3)	34.7 (1.7)	39.9 (1.9)	52.4 (3.5)
How long it takes to get to USC	97,487,270
≤30 minutes	7799	89 (0.7)	87.5 (1.2)	89.6 (1)	88.1 (2.1)
>30 minutes	1029	11 (0.7)	12.5 (1.2)	10.4 (1)	11.9 (2.1)
How difficult it is to get to USC	97,457,495
Difficulty	600	5.9 (0.5)	6.8 (0.7)	7.1 (0.8)	6.7 (1.5)
Not difficult	8233	94.1 (0.5)	93.2 (0.7)	92.9 (0.8)	93.3 (1.5)
Services
Go to USC for preventive health care	97,563,540
No	203	2.3 (0.3)	2.4 (0.4)	2.4 (0.5)	1.3 (0.5)
Yes	8634	97.7 (0.3)	97.6 (0.4)	97.6 (0.5)	98.7 (0.5)
Go to USC for referrals	97,512,933
No	218	2.5 (0.3)	2.1 (0.4)	3.1 (0.6)	3.9 (1.6)
Yes	8612	97.5 (0.3)	97.9 (0.4)	96.9 (0.6)	96.1 (1.6)
USC provider asks about other treatments^{^‡}	94,279,152
No	1444	16.0 (0.8)	14.4 (1.0)	20.6 (1.9)	19.2 (2.5)
Yes	7089	84.0 (0.8)	85.6 (1.0)	79.4 (1.9)	80.8 (2.5)
USC provider listens^{^†}	88,642,483
No	73	0.5 (0.1)	1.8 (0.4)	0.9 (0.3)	0.9 (0.5)
Yes	7803	99.5 (0.1)	98.2 (0.4)	99.1 (0.3)	99.1 (0.5)

Data are % (standard error) unless otherwise indicated.
↵* Bold values indicate total weighted sample.
↵† P < .001, based on χ² tests of the differences between those with and without chronic conditions.
↵‡ P < .01 based on χ² tests of the differences between those with and without chronic conditions.
USC, usual source of care.

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Table 3. Logistic Regression Odds Ratios for Attributes of Primary Care Access and Services According to Race/Ethnicity Among People With Chronic Conditions

Primary Care Attributes	Race/Ethnicity
Primary Care Attributes	Non-Hispanic Black vs. Non-Hispanic White	Hispanic vs. Non-Hispanic White	Non-Hispanic Asian vs. Non-Hispanic White
Access
Have USC
Yes	0.8^* (0.7–1.0)	0.8^{^†} (0.6–0.9)	0.7^* (0.5–0.9)
No	1.0	1.0	1.0
Type of USC
Facility	1.4^{^‡} (1.2–1.6)	1.4^{^†} (1.1–1.7)	0.9 (0.6–1.2)
Person/person in facility	1	1	1
USC specialty
Primary care	1.1 (0.7–1.6)	1.4 (0.8–2.5)	3.0^{^†} (1.3–6.8)
Other	1	1	1
USC location
Office	0.5^{^‡} (0.4–0.6)	0.4^{^‡} (0.3–0.5)	0.7^* (0.5–1.0)
Hospital	1	1	1
Difficulty in contacting USC by phone
Very difficult	0.9 (0.6–1.3)	0.9 (0.7–1.3)	1.0 (0.5–2.0)
Not very difficult	1	1	1
USC has office hours nights/weekends
Yes	1.1 (0.9–1.4)	1.3^{^†} (1.1–1.6)	2.0^{^‡} (1.5–2.8)
No	1	1	1
How long it takes to get to USC
≤30 minutes	0.8 (0.6–1.1)	1.1 (0.9–1.4)	0.8 (0.5–1.3)
>30 minutes	1	1	1
How difficult it is to get to USC
Difficulty	1.0 (0.8–1.3)	0.8 (0.6–1.2)	1.1 (0.6–1.8)
Not difficult	1	1	1
Services
Go to USC for preventive health care
Yes	0.9 (0.6–1.5)	1.0 (0.6–1.8)	1.9 (0.8–4.5)
No	1	1	1
Go to USC for referrals
Yes	1.2 (0.7–2.0)	0.8 (0.5–1.4)	0.6 (0.2–1.5)
No	1	1	1
USC provider listens
Yes	0.4^{^†} (0.2–0.8)	0.9 (0.4–2.1)	0.6 (0.2–2.0)
No	1	1	1
Provider asks about other treatments
Yes	1.1 (0.9–1.3)	0.8 (0.6–1.1)	0.9 (0.6–1.2)
No	1	1	1

Data are odds ratios (95% confidence intervals). Logistic regressions were adjusted for the following personal characteristics: age, sex, insurance, socioeconomic status, metropolitan statistical area, census region, perceived health status, perceived mental health status, activities of daily living, and instrumental activities of daily living.
↵* P < .05 based on test of significance of the odds ratios.
↵† P < .01 based on test of significance of the odds ratios.
↵‡ P < .001 based on test of significance of the odds ratios.
USC, usual source of care.

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Table 4. Logistic Regression Odds Ratios for Attributes of Primary Care Access and Services According to Socioeconomic Status Among People With Chronic Conditions

Primary Care Attributes	Socioeconomic Status
Primary Care Attributes	High vs. Low	Above Average vs. Low	Below Average vs. Low
Access
Have USC
Yes	0.9 (0.7–1.1)	1.3 (1.0–1.6)	1.2 (0.8–1.6)
No	1.0	1.0	1.0
USC type
Facility	1.0 (0.9–1.2)	1.0 (0.8–1.1)	0.9 (0.8–1.1)
Person/Person in facility	1	1	1
USC specialty
Primary care	0.9 (0.6–1.5)	0.8 (0.5–1.4)	1.6 (0.8–3.2)
Other	1	1	1
USC location
Office	1.0 (0.8–1.2)	1.2 (0.9–1.5)	1.1 (0.8–1.4)
Hospital	1	1	1
Difficulty contacting USC by phone
Very difficult	1.3 (0.9–1.9)	1.5 (1.0–2.4)	1.2 (0.7–2.2)
Not very difficult	1	1	1
USC has office hours nights/weekends
Yes	1.1 (0.9–1.3)	1.1 (0.9–1.4)	1.2 (0.9–1.5)
No	1	1	1
How long it takes get to USC
≤30 minutes	1.2 (0.9–1.5)	1.2 (0.9–1.6)	1.2 (0.8–1.6)
>30 minutes	1	1	1
How difficult is it get to USC
Difficulty	0.7^* (0.6–1.0)	0.6^* (0.4–0.9)	0.5^* (0.3–0.9)
Not difficult	1	1	1
Services
Go to USC for preventive health care
Yes	0.7 (0.4–1.2)	0.8 (0.5–1.3)	0.8 (0.4–1.7)
No	1	1	1
Go to USC for referrals
Yes	0.9 (0.5–1.4)	0.8 (0.5–1.4)	1.5 (0.8–3.0)
No	1	1	1
USC provider listens
Yes	0.7 (0.3–1.5)	0.4^* (0.2–0.9)	0.4 (0.1–1.3)
No	1	1	1
Provider asks about other treatments
Yes	1.1 (0.9–1.3)	1.1 (0.9–1.4)	1.4^* (1.1–1.8)
No	1	1	1

Data are odds ratios (95% confidence intervals). Logistic regressions were adjusted for the following personal characteristics: age, race, sex, insurance, metropolitan statistical area, census region, perceived health status, perceived mental health status, activities of daily living, and instrumental activities of daily living.
↵* P < .05 based on test of significance of the odds ratios.
USC, usual source of care.