Factors Affecting the Choice of Hospital-Based Ambulatory Care by the Urban Poor THELMA JEAN SKINNER, PHD, BARBARA S. PRICE, BA, DAVID W. SCOTT, PHD, AND G. ANTHONY GORRY, PHD
Abstract: This study of patients in the outpatient department at an urban hospital revealed that almost all could have reached a neighborhood center in less time and only a small number came to the hospital rather than a neighborhood center out of medical necessity. When the patients were asked about their willingness to obtain treatment at a neighborhood center, 48 per cent were willing, 52 per cent were not. These responses did not vary by demographic or medical characteristics but rather by the patients' stated priorities
regarding medical care. Eighty per cent of those willing to change sites stressed convenience of access as a first priority compared with only 17 per cent of those not willing to change. Emphasis on quality of care (45 per cent) or on familarity with the site (37 per cent) distinguished the group not willing to change. The findings suggest that successful efforts to persuade patients to utilize a neighborhood center must base their appeal on patients' individual priorities. (Am. J. Public Health 67:439-445, 1977)
One of the major innovations in the delivery of medical care during the last decade was the establishment of neighborhood health centers to bring service to the poor. From the standpoint of cost and quality of care, these centers appear to be efficient and effective in providing medical care, 1.2 but a number of problems have prevented them from achieving their full potential impact on ambulatory care in their communities. Among the problems cited as limiting the impact of these centers has been difficulty in educating patients to utilize the new facilities in a manner most advantageous to themselves and to the total system of delivering care in a given region.3'4 In Harris County (Houston), Texas, this difficulty may account for the fact that a large number of patients continue to utilize the outpatient department of the central hospital instead of the seven neighborhood health centers built in part to relieve its load. The outpatient
borhood health centers.* We examined the addresses of 246 patients in the outpatient department to determine whether these patients lived closer to the neighborhood health center than to the hospital. In almost every case, the neighborhood health center proved to be nearer than the hospital. We then asked a panel of five physicians to review each case and to judge whether the patient's problem could have been equally well treated at a neighborhood center. Again, in almost all cases, the neighborhood center was deemed an equally appropriate place for the patient to receive care. Thus we concluded that many patients were choosing to come to the outpatient department of the hospital rather than go to the neighborhood health centers when there were no compelling reasons of convenience or medical necessity. In order to understand why patients were not using the neighborhood centers as sites for primary care, we undertook a second study in the outpatient department at the hospital. We interviewed patients to ascertain what factors influenced their choices of medical facilities. The results of our study are discussed in this paper.
department remains overcrowded while the neighborhood centers could accommodate more patients. As part of a long-range effort to reorganize the services for ambulatory care in the Harris County Hospital District, we analyzed the patient demand at the outpatient facility of the Ben Taub General Hospital to determine the extent to which this demand might be equally well-served by the neigh-
From the Program for Health Management and Department of Community Medicine, Baylor College of Medicine. Address reprint requests to Dr. Thelma Jean Skinner, Program for Health Management, Baylor College of Medicine, Houston, TX 77030. This paper, submitted to the Journal October 26, 1976, was revised and accepted for publication January 14, 1977.
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The Setting The Harris County Hospital District is a tax-supported public authority responsible for providing medical care to ap*Skinner, T. J., Price, B. S., and Gorry, G. A. Is the Neighborhood Health Clinic an Option for the Hospital's Outpatients? A Preliminary Investigation. Submitted for publication.
439
SKINNER, ET AL.
proximately 350,000 indigents residing in Houston and the surrounding area. Until recently, two hospitals were the only facilities available for this purpose: Ben Taub General Hospital which has 473 beds and a large outpatient program with 62 special and general clinics, and Jefferson Davis Hospital which offers obstetrics, physical medicine, pediatrics, and pulmonary services on both an inpatient and outpatient basis. In 1969, the District established a Community Medicine Service to make ambulatory care readily accessible in the neighborhoods of greatest need. Seven neighborhood centers are now in operation. They are in various stages of development as centers of comprehensive care, but all have the professional staff and facilities to deliver primary care to adults and children. The two hospitals provide specialized and inpatient services for the centers' patients in addition to operating their own ambulatory care services. The medical staff of the centers and the hospitals are largely drawn from the faculty and postgraduate trainees of Baylor College of Medicine. Figure 1 graphically depicts the increased utilization of services over the past ten years. Notice that the demand for services at Ben Taub has continued to grow despite the creation of the neighborhood centers. The hospital's outpatient departments are still overcrowded and patients experience long delays for service. Six of the outpatient clinics at Ben Taub were selected as sites for the study. Two of these-the Admitting and Pediatric Clinics-are general clinics providing treatment for a broad range of illnesses. In this regard, they are comparable to the neighborhood centers. These clinics were also selected because they are the largest; together they receive over one-fourth of all visits to the 62 outpatient clinics of the hospital. We chose four specialized clinics as additional sites for the study to determine where those patients go for general care and whether the care they were currently receiving in the specialized clinics could be provided at a neighborhood center. We selected the General Medical Clinic-the largest of the specialized clinics-and two smaller clinics (HyperGROWTH IN DEMAND FOR AMBULATORY CARE IN HARRIS COUNTY
Number of
280 240 200
Outpatient 160 Visits 120 (in thousands)12
Ben Taub
E
Outpatient Department (excluding Emergency Room)
/-
80
/
40
nv
o ,'
vd I,
1966
I
"'" Neighborhood
Procedure Collection of Data Our study was conducted from mid-December 1975, to mid-January 1976 (excluding the holiday season). Because of wide variation in the sizes and types of the clinics of interest, we took a disproportionate sample stratified by clinic. The number of interviews completed in each clinic is presented in Table I along with the relative frequency of patient visits among these clinics.* The latter figures will be used as weights in computing statistics for the total sample (as described in the subsequent section). Table 1 also displays demographic characteristics of the sample. The names of prospective interviewees were obtained from patients' charts as they were prepared for the physician's call. We requested participation from patients (from the patient's mother in the Pediatric Clinic) in the order in which they were listed to see the physician, omitting those whose turn was imminent. There was nothing systematic in
Centers
e-
1968 1970 1972 CALENDAR YEAR
1974
FIGURE 1 -Growth in Demand for Ambulatory Care in Harris County, Texas. 440
tensive and Diabetic) because these treat illnesses which are followed at the neighborhood centers. We also included the Renal Clinic which is designed to treat a complex problem not expected to be followed in a neighborhood center. Since ease of access to a site of care will be considered as a possible factor influencing the patients' choices, we include here some pertinent facts about the operations of the available facilities. Eligibility. Except in cases of emergency, persons who wish to receive treatment at facilities governed by the Harris County Hospital District must first show evidence that they meet established criteria regarding income and residence. A card is then issued which allows a patient to receive care at any of the District's facilities. The patient's freedom to select (and re-select) the site of care is guaranteed, and the District will move the patient's chart from one facility to another as required. Hours. The neighborhood centers are open five days a week, and two nights a week until 8:30 pm. The Admitting and Pediatric Clinics at Ben Taub are also open five days a week, the former until 10:00 pm. Hours are more limited in the specialized clinics: four hours daily Monday through Friday in the General Medical Clinic, and four hours once a week in the three smaller clinics. Appointments. The neighborhood centers routinely see patients by advance appointment, but many "drop-in" patients are also seen. In the Admitting and Pediatric Clinics at Ben Taub, appointments may be made but are not required. In the four specialized clinics, patients are seen by advance appointment only, and only if referred by a physician.
*In reaching our target of 214 completed interviews, we asked 228 patients to participate. Fourteen interviews were not completed due to refusal (three cases), inability to locate the patient (six cases), interruption by the physician (three cases), and inability to communicate with the patient (two cases).
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TABLE 1-Characteristics of the Sample
Clinic
Admitting Pediatric General Medical Diabetic Renal Hypertensive
Ethnicity
n
Relative Frequency of Patient Visits
Age (median)
Black
White
M-A*
54 50 50 20 20 20
40.2 37.1 19.9 1.2 1.0 0.6
53 2 62 50 47 48
81 70 66 70 70 95
15 13 28 15 30
4 17 6 15 0
5
0
Sex (% female)
82 43 80 80 55 60
*Mexican-American
Results
these omissions since interviewing was done at various times of day, i.e., those who were omitted were not regularly those scheduled to be the first patients seen. After we obtained informed consent, we conducted an interview consisting of 26 specific questions with openended responses. Some of the questions concerned the patient's trip to Ben Taub. This description was later used to compare the convenience of a trip to the hospital versus the nearest neighborhood center for each patient. Other questions concerned the reasons for their current visit, the extent of their familiarity with the neighborhood centers, and their intentions to utilize them. Finally, we asked the physician of each interviewed patient for an opinion as to whether the patient's current visit and present problem(s) were such that the types of staffing and facilities available at a neighborhood center (as opposed to the hospital) were adequate for the treatment required. The physicians, 65 in all, gave their responses at the completion of each visit.
The great majority of the patients interviewed count Ben Taub as their regular source of primary care rather than as a back-up facility for specialized, inpatient, or emergency treatment. The weighted aggregate figure was 91.7 per cent. Even those who were patients in the specialized clinics said they look to their specialist or to other clinics in Ben Taub for their general care. This orientation is reflected in Table 2 showing the patients' reported reasons for their visits. Except in the Pediatric Clinic, most of the patients had come for regularly scheduled check on a previously diagnosed condition rather than for treatment of an acute problem. The use of the hospital in this way is especially remarkable in the Admitting Clinic. As its name implies, this clinic is intended to be a front-line receiving station for admission either into the hospital or into a specialized outpatient clinic, but over 40 per cent of the patients interviewed there were being followed at that site for a chronic condition. Utilization of Ben Taub as a regular source of primary care entails a considerable investment of time in travel for the patients in our study. The weighted mean reported time spent en route to Ben Taub was 39 minutes with a range of 10 minutes to two hours. Thirty-five per cent of the patients spent more than 45 minutes en route. In some cases, dependence on public transportation created delays in transit, but over one-half of the patients arrived by automobile. We assessed the convenience of a trip to Ben Taub as compared with a trip to a neighborhood center. Patients' descriptions of their trips to Ben Taub were examined for such
Analysis of Data Because we used a stratified sample in our study, we weighted our results for the individual clinics by the fractions in Table I to obtain our overall estimates of characteristics of the total population served by the clinics. In evaluating contingency tables, we accounted for the disproportionate nature of our sample by using the method of Bhapkar5 as expanded by Nathan6 to obtain Chi-square statistics. The interpretation of those statistics follows the customary procedure.
TABLE 2-Patient's Reported Reason for Visit Clinic
Follow-up for Chronic Condition
First Visit for Acute Illness
Return Visit for Acute Illness
Visit to Assess Test Resuits
Admitting Pediatric General Medical Diabetic Renal Hypertensive
42.6 3.8 92.0 100.0 75.0 100.0
40.7 71.7 4.0 0.0 10.0 0.0
9.3 20.7 0.0 0.0 10.0 0.0
7.4 3.8 4.0 0.0 5.0 0.0
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SKINNER, ET AL.
centers. As seen in Table 3, the percentage varied among the clinics, but the findings clearly indicate that the maldistribution among available facilities is of major proportions.
items as point of departure, destination after treatment, special family arrangements (e.g., for care of young children), number of bus transfers, and ease of obtaining transportation from friends or relatives. We found that none of these factors would be adversely affected by a change to a neighborhood center and so we used straight-line distance from the patient's home to the two possible sites of care as our measure of convenience. We determined that 88.8 per cent lived closer to a neighborhood center than to Ben Taub. An additional 4.6 per cent lived equidistant between Ben Taub and the nearest neighborhood center. A large fraction of the patients, then, were bypassing the neighborhood centers from the standpoint of convenience. To what extent were the patients also bypassing the neighborhood centers from the standpoint of medical management? We asked each patient's physician to indicate whether the patient's current visit could have been managed at a neighborhood center and whether total care for the patient's current problems could be provided by a neighborhood center with occasional procedures being performed at the hospital. We found that, weighted by clinic, approximately 85 per cent of both the visits and problems were judged as manageable at the neighborhood
Knowledge and Attitudes Concerning the Neighborhood Centers We explored the extent of the patients' knowledge of and experience with the centers and their attitudes towards future use of the centers. The patients did not report having heard any negative remarks about the centers (although they might well be reluctant to criticize any aspect of a medical system upon which they are dependent). Weighting the responses by clinic resulted in the following estimates: 39.1 per cent have never heard of the existence of the centers; 60.9 per cent are familiar with the centers to various degrees as depicted in Figure 2. Note that only 6.5 per cent have been treated at a neighborhood center. No one in the sample from the Admitting Clinic, the clinic most comparable to the centers, reported ever having received care at a neighborhood center.
TABLE 3-Outcome of Physicians' Assessment of Manageability in a Neighborhood Center
Clinic
(N)
Admitting Pediatric General Medical Diabetic Renal Hypertensive TOTAL
(53) (52) (50) (20) (20) (20) 215*
Patients with Visits Judged Manageable in a Neighborhood Center
Patients with Problem(s) Judged Manageable in a Neighborhood Center
No. 46 46 43 9 4 15
No. 43 47 43 10 3 15
% 86.8 88.5 86.0 45.0 20.0 75.0
% 81.1 90.4 86.0 50.0 15.0 75.0
*The number of cases (215) reviewed by physicians differs from the number of interviews (214) due to the fact that three mothers each brought two children for treatment in the Pediatric Clinic. The resulting total of 217 patients decreased to 215 because two patients, one in the Admitting Clinic and one in the Pediatric Clinic, left before they saw a physician.
Heard of Centers No 39.1%
Yes 60.9% Knew Location of Nearest Center
No
Yes 40.2%
20.7%
Had Been to a Center No 20.5%
Yes 19.7% Had Been Treated at a Center
No 13.2%
Yes 6.5%
FIGURE 2-Extent of the Patient's Familiarity with the Neighborhood Centers. 442
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CHOICE OF CARE BY THE URBAN POOR
of their services and policies. Weighting the answers by clinic gives us these estimates: 50.8 per cent not willing, 47.0 per cent willing, and 2.2 per cent undecided. Chi-square tests of significance were performed to assess the connection between the patients' answers concerning willingness to go to a neighborhood center and various factors thought to be relevant. Their willingness was not found to vary with their age, sex, or race. Neither did it vary with the length of time they had utilized Ben Taub nor with the particular outpatient clinic they were currently visiting. Moreover, their willingness did not vary with the gravity of their illnesses either as perceived by themselves or as judged by their present physicians (as measured by whether their cases were deemed manageable at a neighborhood health center). The key factor in the patients' willingness to utilize a neighborhood center was found to be their expressed priorities regarding medical care. That is, when asked to give the reasons for their decisions, the patients willing to change to a neighborhood center cited reasons that differed from those offered by the patients not willing to change. Patients who cited more than one reason for their decisions were asked to signify the most important consideration. Table 5 shows the weighted percentages of patients by expressed priorities and willingness to utilize the neighborhood centers. Patients were categorized as placing high priority on quality of care if they made such statements as "I prefer to stay at Ben Taub because I think it has better doctors (more equipment/better service)" or "I will go to a neighborhood center if it has good doctors (good facilities/good care)." Convenience of access was counted as high priority for patients who said "I prefer Ben Taub because it has better hours (is closer/is easier to get to)," or "I would like to change to a neighborhood center if it is more convenient (closer/takes people without appointments)." Devotion to Ben Taub was reflected in comments such as "I want to stay here because I am used to it (know the rules here/have been here a long time)," and "I like Ben Taub but if they tell me to go to a neighborhood center, I will."
The staff at Ben Taub has been requested to inform patients about the neighborhood centers, and signs are displayed urging patients to ask their doctors for appointments at their center. When we asked the patients whether they had ever discussed the centers with the physicians or nurses at Ben Taub, however, no more than three patients in each clinic reported having had any such exchange. No attempt was made to gather corroborating information from the staff. To explore further the matter of familiarity with the centers, we tabulated the degree of knowledge against the relative distance from the neighborhood targeted by each center. Target areas have been demarcated by the Community Medicine Service not as boundaries of eligibility but as census tracts of greatest need. The majority of patients at each center reside in the target areas and publicity about the centers has been directed to these regions. Table 4 displays the weighted percentages of patients in the six clinics at Ben Taub at each level of familiarity with the centers by their residence relative to the target areas. The pattern of the frequencies indicates a statistically significant association between the two variables (x2 = 10.8, p < .05, one-tailed test). The farther a patient lives from the target areas, the less likely he or she was to have much knowledge about the centers. The association, however, is only moderate. A substantial proportion of the patients (33.3 per cent) who came from within the target areas had not heard of the centers and over one-half (57.0 per cent) of those who came from outside these regions had some knowledge of the centers. Those patients at Ben Taub who had at some time been treated at a neighborhood center were asked why they had not gone there for the current visit. The reasons given were quite varied and did not represent significant dissatisfaction with the centers. In fact, when we asked these 18 patients if they intended to seek treatment again at their centers, eight indicated an intention to return to their centers. Finally, we asked those respondents who had never been patients in a neighborhood center if they would be willing to receive care there. For those who had never heard of the centers, the question was preceded by a brief description
TABLE 4-The Relationship Between Residential Distance from a Target Area and Familiarity with the Neighborhood Centers Residence
Familiarity with Centers
Never heard of centers Heard of centers, Did not know location Knew location, Had never been Been to a center TOTAL
< 3 Miles Outside
Inside Target Area
Target Area
> 3 Miles Outside Target Area
Total
N*
13.4
19.4
6.3
39.1
[83]
6.5
12.5
1.7
20.7
[46]
8.6
11.1
0.8
20.5
[45]
11.7 40.2
6.4 49.4
1.6 10.4
19.7 100.0
[40] [214]
*The total number of respondents from the six clinics who comprise the cells is shown in brackets. The percentage given in each cell was obtained by weighting each clinic's sample in proportion to the volume of patient visits shown in Table 1. The percentages, therefore, are more descriptive of the overall population of patients as discussed further in the text.
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SKINNER, ET AL.
TABLE 5-Patients' Priorities and Willingness to Utilize the Neighborhood Centers Priorities
Willing
Not Willing
Total
N*
8.6
23.5
32.1
[69]
access
38.6
9.0
47.6
[82]
Devotion to Ben Taub TOTAL
0.9 48.1
19.4 51.9
20.3 100.0
[42] [193]
Quality of care Convenience of
*The total number of respondents from the six clinics who comprise the cells is shown in brackets. The percentage given in each cell was obtained by weighting each clinic's sample in proportion to the volume of patient visits shown in Table 1. The percentages, therefore, are more descriptive of the overall population of patients as descrbed further in the text. Those patients who were undecided about utilizing the centers or who had utilized them previously are omitted from this table.
The distribution of patients in the table indicates at a statistically significant level (X2 = 107.7, p < .00 1) that patients who preferred to remain at Ben Taub were more likely to place emphasis on quality of care or on loyalty to a familiar site of care. Those who expressed a willingness to utilize the neighborhood centers were more likely to lay great stress on convenience of access to the site of care. The patients' priorities regarding medical care did not vary with sex, age, race, or particular outpatient clinic utilized.
Discussion Virtually all of the patients interviewed in six outpatient clinics at a general hospital serving the poor live closer to a neighborhood center and are taking a long route to care; not many do so out of medical necessity. Part of the explanation for this bypassing lies in the fact that over one-half of the patients reported little or no knowledge of the neighborhood centers and few had ever visited them. Other studies have also found the poor to be markedly unaware of the medical services available to them, other than the hospital.9-1" Merely informing the patients of the existence of a center near them, however, does not guarantee they will alter their site of care. When patients in our study were asked about their willingness to obtain treatment at the centers, their answers were found to vary with their priorities regarding medical care. Those who place greatest importance on quality of care or loyalty to a familiar site of care are less likely to express a desire to change than those who place greatest importance on convenience of access. Several investigators have proposed that proximity is the dominant variable in the choice and use of medical services.10-'4 We found, however, that the concern for distance can be overridden by competing concerns. Studies by Franklin and McLemore,'5 Anderson and Bartkus,16 and Suchman17 also stress that knowledge of patients' values and attitudes is crucial for understanding variations in the choice of medical facilities. The pattern we noted in our sample regarding the relationship between particular priorities and choice of site is consistent with the results of an investigation by Hillman and Charney.4 When patients of a neighborhood health center 444
were asked where they would seek care if all care were free, those for whom convenience was of high priority cited the neighborhood center while those for whom quality of care was of high priority cited hospital clinics. Bellin and Geiger3 also found that convenience was of highest priority to patients who had chosen a neighborhood health center as their source of care. Loyalty to the site of care was found by Robertson et al.8 to override the matter of convenience among patients participating in a special program at a hospital clinic when they were asked about their intentions to utilize the somewhat equivalent and more convenient source of care, the neighborhood center. McKinlay has pointed out that more attention should be given to the forms in which medical care can be provided and to the congruence of any given form with the expressed values of the various groups that constitute a society.'8 We want to add that care must be taken in choosing the criteria by which such groups are defined and identified. As our study has demonstrated, the assumption that a group more or less homogeneous in sociodemographic terms will also be homogeneous in its stated values is ill-founded. The study raises a number of other points which merit consideration. First, we would like to learn more about what it means operationally for patients to give reasons for a choice regarding a present or proposed site for medical care. How do they weigh the myriad aspects of the situation in constructing a rationale? Second, it would be of interest to investigate the priorities of patients at the neighborhood centers. Finally, what are the implications of our findings for re-directing patients from the hospital clinics to the neighborhood centers? Our findings suggest that the success of an effort at redirection would hinge in part on the physicians at Ben Taub. As we pointed out earlier, many of the patients are coming there for a regularly scheduled check on a chronic illness. Unless their physician suggests that they instead go to a neighborhood center for such checks, we doubt that they would do so on their own. Success at re-direction, however, depends upon more than a suggestion from the physician about the site of the next appointment. Since patients are free to choose their facility, any effort at intervention must base its appeal on what is of greatest importance to them. For those patients currently using the hospital whose primary interest is in conveAJPH May, 1977, Vol.67, No.5
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nience of access, we would expect high yield from an educational campaign on the location of the neighborhood centers and the best routes to travel, especially if such logistical help were offered on an individual basis. For patients with other interests, we have lower expectations about the usefulness of merely imparting information, although some of the patients whose loyalty rests with Ben Taub Hospital might be persuaded by learning of the connection in staffing, records, back-up services, and eligibility that exists between the hospital and the centers. Patients at Ben Taub whose first priority is quality of care will not be easily swayed from the view that a large hospital is the surest place to obtain it. Almost all the information about medicine that reaches the public domain-from educational reports to entertaining programs-serves to emphasize the advantages of the medical center with its sophisticated equipment and highly trained staff. Such emphasis is particularly strong in Harris County where the Texas Medical Center, in which Ben Taub is located, receives considerable publicity. There is some evidence, however, that patients who do utilize the neighborhood centers are satisfied with the quality of care received there.* The evidence is fragmentary, but it does suggest the possibility that once the hospital's patients have had personal experience at the centers, they will find their requirements well met by the new facility. Securing the first trial is the problem, and given their confidence in the medical center it can probably be effectuated only by a straightforward referral from their physician which stresses his/her opinion that they can be well-served by the new facility. Though such a varied program of intervention would require a substantial outlay of time and personnel, it is apparent that more superficial efforts leave large numbers of patients unaffected. Changing long-standing patterns of utilization will be an arduous task, but the significant successes that neighborhood centers have had prove it is not an impossible one. An important first step along these lines is recognizing the different factors which influence the choice of facilities for ambulatory care. *Guardiola, G., Beggs-Baker, S., Vallbona, C. et al. Health Attitudes of Mexican-Americans in an Urban Environment. Baylor College of Medicine, Mimeo, 1973. Hackney, A. M. A Comparative Study of the Attitudes of Welfare and Fee-for-Service Parents Toward the Competencies of the Nursing Staff and the Management of the Pediatric Department of a Southern Neighborhood Health Center. University of Southern California, Unpublished thesis, 1976. Thomas, L. P. Baytown Clinic: An Investigation into the Restraints to More Effective Health Care Delivery. University of Texas School of Public Health, Unpublished thesis, 1972.
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REFERENCES 1. Morehead, M. A., Donaldson, R. S., and Seravalli, M. R. Comparisons between OEO neighborhood health centers and other health care providers of ratings of the quality of health care. Am. J. Public Health 61:1294-1306, 1971. 2. Sparer, G., and Anderson, A. Cost of services at neighborhood health centers-A comparative analysis. New Eng. J. Med. 286:1241-1245, 1972. 3. Bellin, S. S., and Geiger, H. J. Actual public acceptance of the neighborhood health center by the urban poor. JAMA 214:21472153, 1970. 4. Hillman, B., and Charney, E. A neighborhood health center: What the patients know and think of its operation. Med. Care 10:336-344, 1972. 5. Bhapkar, V. P. Some tests for categorical data. Annals of Math. Statis. 32:72-83, 1961. 6. Nathan, G. Tests of Independence in Contingency Tables from Stratified Samples. In N. Johnson and H. Smith, Eds. New Developments in Survey Sampling. Wiley-Interscience, New York, 1969. 7. Comely, P., and Bigman, S. Acquaintance with municipal government health services in a low-income urban population. Am. J. Public Health 52:1877-1886, 1962. 8. Robertson, L. S., Kosa, J., Alpert, J. J., et al. Anticipated acceptance of neighborhood health centers by the urban poor. JAMA 205: 107-110, 1968. 9. White, M. K., Alpert, J. J., and Kosa J. Hard to reach families in a comprehensive care program. JAMA 201:801-806, 1967. 10. Bodenheimer, T. S. Patterns of American ambulatory care. Inquiry 7:26-37, 1970. 11. Borkow, G. Use of alternate facilities by consumers at the providence health centers. Inquiry 10:54-58, 1973. 12. Brooks, C. H. Associations among distance, patient satisfaction and utilization of two types of inner-city clinics. Med. Care 11:373-383, 1973. 13. Shannon, G. W., Bashur, R. L., and Metzner, C. A. The concept of distance as a factor in accessibility and utilization of health care. Med. Care Rev. 26:143-161, 1969. 14. Weiss, J. E., and Greenlick, M. R. Determinants of medical care utilization: The effect of social class and distance on contacts with the medical care system. Med. Care 8:456-462, 1970. 15. Franklin, B. J. and McLemore, S. D. Factors affecting the choice of medical care among university students. J. Health Soc. Behav. 11:311-319, 1970. 16. Anderson, J. G., and Bartkus, D. E. Choice of medical care: A behavioral model of health and illness behavior. J. Health Soc. Behav. 14:348-362, 1973. 17. Suchman, C. A. Social patterns of illness and medical care. J. Health Hum. Behav. 6:2-16, 1965. 18. McKinlay, J. Some approaches and problems in the study of the use of services-An overview. J. Health Soc. Behav. 13:115152, 1972.
ACKNOWLEDGMENTS This study was supported in part by Biomedical Research Support Grant RR05425 from the U.S. Public Health Service and in part by HL 17269-02 (IV) P-14 EVAL from the National Heart, Lung, and Blood Institute.
445
Abstract: This study of patients in the outpatient department at an urban hospital revealed that almost all could have reached a neighborhood center in less time and only a small number came to the hospital rather than a neighborhood center out of medical necessity. When the patients were asked about their willingness to obtain treatment at a neighborhood center, 48 per cent were willing, 52 per cent were not. These responses did not vary by demographic or medical characteristics but rather by the patients' stated priorities
regarding medical care. Eighty per cent of those willing to change sites stressed convenience of access as a first priority compared with only 17 per cent of those not willing to change. Emphasis on quality of care (45 per cent) or on familarity with the site (37 per cent) distinguished the group not willing to change. The findings suggest that successful efforts to persuade patients to utilize a neighborhood center must base their appeal on patients' individual priorities. (Am. J. Public Health 67:439-445, 1977)
One of the major innovations in the delivery of medical care during the last decade was the establishment of neighborhood health centers to bring service to the poor. From the standpoint of cost and quality of care, these centers appear to be efficient and effective in providing medical care, 1.2 but a number of problems have prevented them from achieving their full potential impact on ambulatory care in their communities. Among the problems cited as limiting the impact of these centers has been difficulty in educating patients to utilize the new facilities in a manner most advantageous to themselves and to the total system of delivering care in a given region.3'4 In Harris County (Houston), Texas, this difficulty may account for the fact that a large number of patients continue to utilize the outpatient department of the central hospital instead of the seven neighborhood health centers built in part to relieve its load. The outpatient
borhood health centers.* We examined the addresses of 246 patients in the outpatient department to determine whether these patients lived closer to the neighborhood health center than to the hospital. In almost every case, the neighborhood health center proved to be nearer than the hospital. We then asked a panel of five physicians to review each case and to judge whether the patient's problem could have been equally well treated at a neighborhood center. Again, in almost all cases, the neighborhood center was deemed an equally appropriate place for the patient to receive care. Thus we concluded that many patients were choosing to come to the outpatient department of the hospital rather than go to the neighborhood health centers when there were no compelling reasons of convenience or medical necessity. In order to understand why patients were not using the neighborhood centers as sites for primary care, we undertook a second study in the outpatient department at the hospital. We interviewed patients to ascertain what factors influenced their choices of medical facilities. The results of our study are discussed in this paper.
department remains overcrowded while the neighborhood centers could accommodate more patients. As part of a long-range effort to reorganize the services for ambulatory care in the Harris County Hospital District, we analyzed the patient demand at the outpatient facility of the Ben Taub General Hospital to determine the extent to which this demand might be equally well-served by the neigh-
From the Program for Health Management and Department of Community Medicine, Baylor College of Medicine. Address reprint requests to Dr. Thelma Jean Skinner, Program for Health Management, Baylor College of Medicine, Houston, TX 77030. This paper, submitted to the Journal October 26, 1976, was revised and accepted for publication January 14, 1977.
AJPH May, 1977, Vol. 67, No. 5
The Setting The Harris County Hospital District is a tax-supported public authority responsible for providing medical care to ap*Skinner, T. J., Price, B. S., and Gorry, G. A. Is the Neighborhood Health Clinic an Option for the Hospital's Outpatients? A Preliminary Investigation. Submitted for publication.
439
SKINNER, ET AL.
proximately 350,000 indigents residing in Houston and the surrounding area. Until recently, two hospitals were the only facilities available for this purpose: Ben Taub General Hospital which has 473 beds and a large outpatient program with 62 special and general clinics, and Jefferson Davis Hospital which offers obstetrics, physical medicine, pediatrics, and pulmonary services on both an inpatient and outpatient basis. In 1969, the District established a Community Medicine Service to make ambulatory care readily accessible in the neighborhoods of greatest need. Seven neighborhood centers are now in operation. They are in various stages of development as centers of comprehensive care, but all have the professional staff and facilities to deliver primary care to adults and children. The two hospitals provide specialized and inpatient services for the centers' patients in addition to operating their own ambulatory care services. The medical staff of the centers and the hospitals are largely drawn from the faculty and postgraduate trainees of Baylor College of Medicine. Figure 1 graphically depicts the increased utilization of services over the past ten years. Notice that the demand for services at Ben Taub has continued to grow despite the creation of the neighborhood centers. The hospital's outpatient departments are still overcrowded and patients experience long delays for service. Six of the outpatient clinics at Ben Taub were selected as sites for the study. Two of these-the Admitting and Pediatric Clinics-are general clinics providing treatment for a broad range of illnesses. In this regard, they are comparable to the neighborhood centers. These clinics were also selected because they are the largest; together they receive over one-fourth of all visits to the 62 outpatient clinics of the hospital. We chose four specialized clinics as additional sites for the study to determine where those patients go for general care and whether the care they were currently receiving in the specialized clinics could be provided at a neighborhood center. We selected the General Medical Clinic-the largest of the specialized clinics-and two smaller clinics (HyperGROWTH IN DEMAND FOR AMBULATORY CARE IN HARRIS COUNTY
Number of
280 240 200
Outpatient 160 Visits 120 (in thousands)12
Ben Taub
E
Outpatient Department (excluding Emergency Room)
/-
80
/
40
nv
o ,'
vd I,
1966
I
"'" Neighborhood
Procedure Collection of Data Our study was conducted from mid-December 1975, to mid-January 1976 (excluding the holiday season). Because of wide variation in the sizes and types of the clinics of interest, we took a disproportionate sample stratified by clinic. The number of interviews completed in each clinic is presented in Table I along with the relative frequency of patient visits among these clinics.* The latter figures will be used as weights in computing statistics for the total sample (as described in the subsequent section). Table 1 also displays demographic characteristics of the sample. The names of prospective interviewees were obtained from patients' charts as they were prepared for the physician's call. We requested participation from patients (from the patient's mother in the Pediatric Clinic) in the order in which they were listed to see the physician, omitting those whose turn was imminent. There was nothing systematic in
Centers
e-
1968 1970 1972 CALENDAR YEAR
1974
FIGURE 1 -Growth in Demand for Ambulatory Care in Harris County, Texas. 440
tensive and Diabetic) because these treat illnesses which are followed at the neighborhood centers. We also included the Renal Clinic which is designed to treat a complex problem not expected to be followed in a neighborhood center. Since ease of access to a site of care will be considered as a possible factor influencing the patients' choices, we include here some pertinent facts about the operations of the available facilities. Eligibility. Except in cases of emergency, persons who wish to receive treatment at facilities governed by the Harris County Hospital District must first show evidence that they meet established criteria regarding income and residence. A card is then issued which allows a patient to receive care at any of the District's facilities. The patient's freedom to select (and re-select) the site of care is guaranteed, and the District will move the patient's chart from one facility to another as required. Hours. The neighborhood centers are open five days a week, and two nights a week until 8:30 pm. The Admitting and Pediatric Clinics at Ben Taub are also open five days a week, the former until 10:00 pm. Hours are more limited in the specialized clinics: four hours daily Monday through Friday in the General Medical Clinic, and four hours once a week in the three smaller clinics. Appointments. The neighborhood centers routinely see patients by advance appointment, but many "drop-in" patients are also seen. In the Admitting and Pediatric Clinics at Ben Taub, appointments may be made but are not required. In the four specialized clinics, patients are seen by advance appointment only, and only if referred by a physician.
*In reaching our target of 214 completed interviews, we asked 228 patients to participate. Fourteen interviews were not completed due to refusal (three cases), inability to locate the patient (six cases), interruption by the physician (three cases), and inability to communicate with the patient (two cases).
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CHOICE OF CARE BY THE URBAN POOR
TABLE 1-Characteristics of the Sample
Clinic
Admitting Pediatric General Medical Diabetic Renal Hypertensive
Ethnicity
n
Relative Frequency of Patient Visits
Age (median)
Black
White
M-A*
54 50 50 20 20 20
40.2 37.1 19.9 1.2 1.0 0.6
53 2 62 50 47 48
81 70 66 70 70 95
15 13 28 15 30
4 17 6 15 0
5
0
Sex (% female)
82 43 80 80 55 60
*Mexican-American
Results
these omissions since interviewing was done at various times of day, i.e., those who were omitted were not regularly those scheduled to be the first patients seen. After we obtained informed consent, we conducted an interview consisting of 26 specific questions with openended responses. Some of the questions concerned the patient's trip to Ben Taub. This description was later used to compare the convenience of a trip to the hospital versus the nearest neighborhood center for each patient. Other questions concerned the reasons for their current visit, the extent of their familiarity with the neighborhood centers, and their intentions to utilize them. Finally, we asked the physician of each interviewed patient for an opinion as to whether the patient's current visit and present problem(s) were such that the types of staffing and facilities available at a neighborhood center (as opposed to the hospital) were adequate for the treatment required. The physicians, 65 in all, gave their responses at the completion of each visit.
The great majority of the patients interviewed count Ben Taub as their regular source of primary care rather than as a back-up facility for specialized, inpatient, or emergency treatment. The weighted aggregate figure was 91.7 per cent. Even those who were patients in the specialized clinics said they look to their specialist or to other clinics in Ben Taub for their general care. This orientation is reflected in Table 2 showing the patients' reported reasons for their visits. Except in the Pediatric Clinic, most of the patients had come for regularly scheduled check on a previously diagnosed condition rather than for treatment of an acute problem. The use of the hospital in this way is especially remarkable in the Admitting Clinic. As its name implies, this clinic is intended to be a front-line receiving station for admission either into the hospital or into a specialized outpatient clinic, but over 40 per cent of the patients interviewed there were being followed at that site for a chronic condition. Utilization of Ben Taub as a regular source of primary care entails a considerable investment of time in travel for the patients in our study. The weighted mean reported time spent en route to Ben Taub was 39 minutes with a range of 10 minutes to two hours. Thirty-five per cent of the patients spent more than 45 minutes en route. In some cases, dependence on public transportation created delays in transit, but over one-half of the patients arrived by automobile. We assessed the convenience of a trip to Ben Taub as compared with a trip to a neighborhood center. Patients' descriptions of their trips to Ben Taub were examined for such
Analysis of Data Because we used a stratified sample in our study, we weighted our results for the individual clinics by the fractions in Table I to obtain our overall estimates of characteristics of the total population served by the clinics. In evaluating contingency tables, we accounted for the disproportionate nature of our sample by using the method of Bhapkar5 as expanded by Nathan6 to obtain Chi-square statistics. The interpretation of those statistics follows the customary procedure.
TABLE 2-Patient's Reported Reason for Visit Clinic
Follow-up for Chronic Condition
First Visit for Acute Illness
Return Visit for Acute Illness
Visit to Assess Test Resuits
Admitting Pediatric General Medical Diabetic Renal Hypertensive
42.6 3.8 92.0 100.0 75.0 100.0
40.7 71.7 4.0 0.0 10.0 0.0
9.3 20.7 0.0 0.0 10.0 0.0
7.4 3.8 4.0 0.0 5.0 0.0
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SKINNER, ET AL.
centers. As seen in Table 3, the percentage varied among the clinics, but the findings clearly indicate that the maldistribution among available facilities is of major proportions.
items as point of departure, destination after treatment, special family arrangements (e.g., for care of young children), number of bus transfers, and ease of obtaining transportation from friends or relatives. We found that none of these factors would be adversely affected by a change to a neighborhood center and so we used straight-line distance from the patient's home to the two possible sites of care as our measure of convenience. We determined that 88.8 per cent lived closer to a neighborhood center than to Ben Taub. An additional 4.6 per cent lived equidistant between Ben Taub and the nearest neighborhood center. A large fraction of the patients, then, were bypassing the neighborhood centers from the standpoint of convenience. To what extent were the patients also bypassing the neighborhood centers from the standpoint of medical management? We asked each patient's physician to indicate whether the patient's current visit could have been managed at a neighborhood center and whether total care for the patient's current problems could be provided by a neighborhood center with occasional procedures being performed at the hospital. We found that, weighted by clinic, approximately 85 per cent of both the visits and problems were judged as manageable at the neighborhood
Knowledge and Attitudes Concerning the Neighborhood Centers We explored the extent of the patients' knowledge of and experience with the centers and their attitudes towards future use of the centers. The patients did not report having heard any negative remarks about the centers (although they might well be reluctant to criticize any aspect of a medical system upon which they are dependent). Weighting the responses by clinic resulted in the following estimates: 39.1 per cent have never heard of the existence of the centers; 60.9 per cent are familiar with the centers to various degrees as depicted in Figure 2. Note that only 6.5 per cent have been treated at a neighborhood center. No one in the sample from the Admitting Clinic, the clinic most comparable to the centers, reported ever having received care at a neighborhood center.
TABLE 3-Outcome of Physicians' Assessment of Manageability in a Neighborhood Center
Clinic
(N)
Admitting Pediatric General Medical Diabetic Renal Hypertensive TOTAL
(53) (52) (50) (20) (20) (20) 215*
Patients with Visits Judged Manageable in a Neighborhood Center
Patients with Problem(s) Judged Manageable in a Neighborhood Center
No. 46 46 43 9 4 15
No. 43 47 43 10 3 15
% 86.8 88.5 86.0 45.0 20.0 75.0
% 81.1 90.4 86.0 50.0 15.0 75.0
*The number of cases (215) reviewed by physicians differs from the number of interviews (214) due to the fact that three mothers each brought two children for treatment in the Pediatric Clinic. The resulting total of 217 patients decreased to 215 because two patients, one in the Admitting Clinic and one in the Pediatric Clinic, left before they saw a physician.
Heard of Centers No 39.1%
Yes 60.9% Knew Location of Nearest Center
No
Yes 40.2%
20.7%
Had Been to a Center No 20.5%
Yes 19.7% Had Been Treated at a Center
No 13.2%
Yes 6.5%
FIGURE 2-Extent of the Patient's Familiarity with the Neighborhood Centers. 442
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CHOICE OF CARE BY THE URBAN POOR
of their services and policies. Weighting the answers by clinic gives us these estimates: 50.8 per cent not willing, 47.0 per cent willing, and 2.2 per cent undecided. Chi-square tests of significance were performed to assess the connection between the patients' answers concerning willingness to go to a neighborhood center and various factors thought to be relevant. Their willingness was not found to vary with their age, sex, or race. Neither did it vary with the length of time they had utilized Ben Taub nor with the particular outpatient clinic they were currently visiting. Moreover, their willingness did not vary with the gravity of their illnesses either as perceived by themselves or as judged by their present physicians (as measured by whether their cases were deemed manageable at a neighborhood health center). The key factor in the patients' willingness to utilize a neighborhood center was found to be their expressed priorities regarding medical care. That is, when asked to give the reasons for their decisions, the patients willing to change to a neighborhood center cited reasons that differed from those offered by the patients not willing to change. Patients who cited more than one reason for their decisions were asked to signify the most important consideration. Table 5 shows the weighted percentages of patients by expressed priorities and willingness to utilize the neighborhood centers. Patients were categorized as placing high priority on quality of care if they made such statements as "I prefer to stay at Ben Taub because I think it has better doctors (more equipment/better service)" or "I will go to a neighborhood center if it has good doctors (good facilities/good care)." Convenience of access was counted as high priority for patients who said "I prefer Ben Taub because it has better hours (is closer/is easier to get to)," or "I would like to change to a neighborhood center if it is more convenient (closer/takes people without appointments)." Devotion to Ben Taub was reflected in comments such as "I want to stay here because I am used to it (know the rules here/have been here a long time)," and "I like Ben Taub but if they tell me to go to a neighborhood center, I will."
The staff at Ben Taub has been requested to inform patients about the neighborhood centers, and signs are displayed urging patients to ask their doctors for appointments at their center. When we asked the patients whether they had ever discussed the centers with the physicians or nurses at Ben Taub, however, no more than three patients in each clinic reported having had any such exchange. No attempt was made to gather corroborating information from the staff. To explore further the matter of familiarity with the centers, we tabulated the degree of knowledge against the relative distance from the neighborhood targeted by each center. Target areas have been demarcated by the Community Medicine Service not as boundaries of eligibility but as census tracts of greatest need. The majority of patients at each center reside in the target areas and publicity about the centers has been directed to these regions. Table 4 displays the weighted percentages of patients in the six clinics at Ben Taub at each level of familiarity with the centers by their residence relative to the target areas. The pattern of the frequencies indicates a statistically significant association between the two variables (x2 = 10.8, p < .05, one-tailed test). The farther a patient lives from the target areas, the less likely he or she was to have much knowledge about the centers. The association, however, is only moderate. A substantial proportion of the patients (33.3 per cent) who came from within the target areas had not heard of the centers and over one-half (57.0 per cent) of those who came from outside these regions had some knowledge of the centers. Those patients at Ben Taub who had at some time been treated at a neighborhood center were asked why they had not gone there for the current visit. The reasons given were quite varied and did not represent significant dissatisfaction with the centers. In fact, when we asked these 18 patients if they intended to seek treatment again at their centers, eight indicated an intention to return to their centers. Finally, we asked those respondents who had never been patients in a neighborhood center if they would be willing to receive care there. For those who had never heard of the centers, the question was preceded by a brief description
TABLE 4-The Relationship Between Residential Distance from a Target Area and Familiarity with the Neighborhood Centers Residence
Familiarity with Centers
Never heard of centers Heard of centers, Did not know location Knew location, Had never been Been to a center TOTAL
< 3 Miles Outside
Inside Target Area
Target Area
> 3 Miles Outside Target Area
Total
N*
13.4
19.4
6.3
39.1
[83]
6.5
12.5
1.7
20.7
[46]
8.6
11.1
0.8
20.5
[45]
11.7 40.2
6.4 49.4
1.6 10.4
19.7 100.0
[40] [214]
*The total number of respondents from the six clinics who comprise the cells is shown in brackets. The percentage given in each cell was obtained by weighting each clinic's sample in proportion to the volume of patient visits shown in Table 1. The percentages, therefore, are more descriptive of the overall population of patients as discussed further in the text.
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443
SKINNER, ET AL.
TABLE 5-Patients' Priorities and Willingness to Utilize the Neighborhood Centers Priorities
Willing
Not Willing
Total
N*
8.6
23.5
32.1
[69]
access
38.6
9.0
47.6
[82]
Devotion to Ben Taub TOTAL
0.9 48.1
19.4 51.9
20.3 100.0
[42] [193]
Quality of care Convenience of
*The total number of respondents from the six clinics who comprise the cells is shown in brackets. The percentage given in each cell was obtained by weighting each clinic's sample in proportion to the volume of patient visits shown in Table 1. The percentages, therefore, are more descriptive of the overall population of patients as descrbed further in the text. Those patients who were undecided about utilizing the centers or who had utilized them previously are omitted from this table.
The distribution of patients in the table indicates at a statistically significant level (X2 = 107.7, p < .00 1) that patients who preferred to remain at Ben Taub were more likely to place emphasis on quality of care or on loyalty to a familiar site of care. Those who expressed a willingness to utilize the neighborhood centers were more likely to lay great stress on convenience of access to the site of care. The patients' priorities regarding medical care did not vary with sex, age, race, or particular outpatient clinic utilized.
Discussion Virtually all of the patients interviewed in six outpatient clinics at a general hospital serving the poor live closer to a neighborhood center and are taking a long route to care; not many do so out of medical necessity. Part of the explanation for this bypassing lies in the fact that over one-half of the patients reported little or no knowledge of the neighborhood centers and few had ever visited them. Other studies have also found the poor to be markedly unaware of the medical services available to them, other than the hospital.9-1" Merely informing the patients of the existence of a center near them, however, does not guarantee they will alter their site of care. When patients in our study were asked about their willingness to obtain treatment at the centers, their answers were found to vary with their priorities regarding medical care. Those who place greatest importance on quality of care or loyalty to a familiar site of care are less likely to express a desire to change than those who place greatest importance on convenience of access. Several investigators have proposed that proximity is the dominant variable in the choice and use of medical services.10-'4 We found, however, that the concern for distance can be overridden by competing concerns. Studies by Franklin and McLemore,'5 Anderson and Bartkus,16 and Suchman17 also stress that knowledge of patients' values and attitudes is crucial for understanding variations in the choice of medical facilities. The pattern we noted in our sample regarding the relationship between particular priorities and choice of site is consistent with the results of an investigation by Hillman and Charney.4 When patients of a neighborhood health center 444
were asked where they would seek care if all care were free, those for whom convenience was of high priority cited the neighborhood center while those for whom quality of care was of high priority cited hospital clinics. Bellin and Geiger3 also found that convenience was of highest priority to patients who had chosen a neighborhood health center as their source of care. Loyalty to the site of care was found by Robertson et al.8 to override the matter of convenience among patients participating in a special program at a hospital clinic when they were asked about their intentions to utilize the somewhat equivalent and more convenient source of care, the neighborhood center. McKinlay has pointed out that more attention should be given to the forms in which medical care can be provided and to the congruence of any given form with the expressed values of the various groups that constitute a society.'8 We want to add that care must be taken in choosing the criteria by which such groups are defined and identified. As our study has demonstrated, the assumption that a group more or less homogeneous in sociodemographic terms will also be homogeneous in its stated values is ill-founded. The study raises a number of other points which merit consideration. First, we would like to learn more about what it means operationally for patients to give reasons for a choice regarding a present or proposed site for medical care. How do they weigh the myriad aspects of the situation in constructing a rationale? Second, it would be of interest to investigate the priorities of patients at the neighborhood centers. Finally, what are the implications of our findings for re-directing patients from the hospital clinics to the neighborhood centers? Our findings suggest that the success of an effort at redirection would hinge in part on the physicians at Ben Taub. As we pointed out earlier, many of the patients are coming there for a regularly scheduled check on a chronic illness. Unless their physician suggests that they instead go to a neighborhood center for such checks, we doubt that they would do so on their own. Success at re-direction, however, depends upon more than a suggestion from the physician about the site of the next appointment. Since patients are free to choose their facility, any effort at intervention must base its appeal on what is of greatest importance to them. For those patients currently using the hospital whose primary interest is in conveAJPH May, 1977, Vol.67, No.5
CHOICE OF CARE BY THE URBAN POOR
nience of access, we would expect high yield from an educational campaign on the location of the neighborhood centers and the best routes to travel, especially if such logistical help were offered on an individual basis. For patients with other interests, we have lower expectations about the usefulness of merely imparting information, although some of the patients whose loyalty rests with Ben Taub Hospital might be persuaded by learning of the connection in staffing, records, back-up services, and eligibility that exists between the hospital and the centers. Patients at Ben Taub whose first priority is quality of care will not be easily swayed from the view that a large hospital is the surest place to obtain it. Almost all the information about medicine that reaches the public domain-from educational reports to entertaining programs-serves to emphasize the advantages of the medical center with its sophisticated equipment and highly trained staff. Such emphasis is particularly strong in Harris County where the Texas Medical Center, in which Ben Taub is located, receives considerable publicity. There is some evidence, however, that patients who do utilize the neighborhood centers are satisfied with the quality of care received there.* The evidence is fragmentary, but it does suggest the possibility that once the hospital's patients have had personal experience at the centers, they will find their requirements well met by the new facility. Securing the first trial is the problem, and given their confidence in the medical center it can probably be effectuated only by a straightforward referral from their physician which stresses his/her opinion that they can be well-served by the new facility. Though such a varied program of intervention would require a substantial outlay of time and personnel, it is apparent that more superficial efforts leave large numbers of patients unaffected. Changing long-standing patterns of utilization will be an arduous task, but the significant successes that neighborhood centers have had prove it is not an impossible one. An important first step along these lines is recognizing the different factors which influence the choice of facilities for ambulatory care. *Guardiola, G., Beggs-Baker, S., Vallbona, C. et al. Health Attitudes of Mexican-Americans in an Urban Environment. Baylor College of Medicine, Mimeo, 1973. Hackney, A. M. A Comparative Study of the Attitudes of Welfare and Fee-for-Service Parents Toward the Competencies of the Nursing Staff and the Management of the Pediatric Department of a Southern Neighborhood Health Center. University of Southern California, Unpublished thesis, 1976. Thomas, L. P. Baytown Clinic: An Investigation into the Restraints to More Effective Health Care Delivery. University of Texas School of Public Health, Unpublished thesis, 1972.
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REFERENCES 1. Morehead, M. A., Donaldson, R. S., and Seravalli, M. R. Comparisons between OEO neighborhood health centers and other health care providers of ratings of the quality of health care. Am. J. Public Health 61:1294-1306, 1971. 2. Sparer, G., and Anderson, A. Cost of services at neighborhood health centers-A comparative analysis. New Eng. J. Med. 286:1241-1245, 1972. 3. Bellin, S. S., and Geiger, H. J. Actual public acceptance of the neighborhood health center by the urban poor. JAMA 214:21472153, 1970. 4. Hillman, B., and Charney, E. A neighborhood health center: What the patients know and think of its operation. Med. Care 10:336-344, 1972. 5. Bhapkar, V. P. Some tests for categorical data. Annals of Math. Statis. 32:72-83, 1961. 6. Nathan, G. Tests of Independence in Contingency Tables from Stratified Samples. In N. Johnson and H. Smith, Eds. New Developments in Survey Sampling. Wiley-Interscience, New York, 1969. 7. Comely, P., and Bigman, S. Acquaintance with municipal government health services in a low-income urban population. Am. J. Public Health 52:1877-1886, 1962. 8. Robertson, L. S., Kosa, J., Alpert, J. J., et al. Anticipated acceptance of neighborhood health centers by the urban poor. JAMA 205: 107-110, 1968. 9. White, M. K., Alpert, J. J., and Kosa J. Hard to reach families in a comprehensive care program. JAMA 201:801-806, 1967. 10. Bodenheimer, T. S. Patterns of American ambulatory care. Inquiry 7:26-37, 1970. 11. Borkow, G. Use of alternate facilities by consumers at the providence health centers. Inquiry 10:54-58, 1973. 12. Brooks, C. H. Associations among distance, patient satisfaction and utilization of two types of inner-city clinics. Med. Care 11:373-383, 1973. 13. Shannon, G. W., Bashur, R. L., and Metzner, C. A. The concept of distance as a factor in accessibility and utilization of health care. Med. Care Rev. 26:143-161, 1969. 14. Weiss, J. E., and Greenlick, M. R. Determinants of medical care utilization: The effect of social class and distance on contacts with the medical care system. Med. Care 8:456-462, 1970. 15. Franklin, B. J. and McLemore, S. D. Factors affecting the choice of medical care among university students. J. Health Soc. Behav. 11:311-319, 1970. 16. Anderson, J. G., and Bartkus, D. E. Choice of medical care: A behavioral model of health and illness behavior. J. Health Soc. Behav. 14:348-362, 1973. 17. Suchman, C. A. Social patterns of illness and medical care. J. Health Hum. Behav. 6:2-16, 1965. 18. McKinlay, J. Some approaches and problems in the study of the use of services-An overview. J. Health Soc. Behav. 13:115152, 1972.
ACKNOWLEDGMENTS This study was supported in part by Biomedical Research Support Grant RR05425 from the U.S. Public Health Service and in part by HL 17269-02 (IV) P-14 EVAL from the National Heart, Lung, and Blood Institute.
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