Journal of Community Health Vol. 17, No. 5, October 1992
UTILIZATION OF PEDIATRIC HEALTH SERVICES IN JERUSALEM Yehuda Neumark, MPH; Hava Pahi, MD, MPH; Milka Donchin, MD, MPH; Avi-Yacar Ellencweig, PhD, MPH, MBA
ABSTRACT: T h e high rate of utilization of health services and rising health care costs in Israel, have prompted the need for refi)rm of the health care system. Preventive and curative aspects of mother and child health care in Israel have traditionally been addressed by indep e n d e n t but parallel health systems. Prior to the pilot integration of these services, current patterns of utilization of health services by children d u r i n g their first year of life, and determinants of use, were analyzed. Mothers of 651 children from five neighborhoods, representing the middle-low, middle and upper social class Jewish population were interviewed. Overall, a high degree of compliance with reco m m e n d e d visits to the preventive family health centers was found, with an average of eleven visits to the public health physician or nurse. The children also made an average of 12 visits to curative practitioners. Combined with all other health care consuhations, these children averaged 26 health care visits in the first year of life. This pattern of frequent visitations, and its determinants, is discussed in context of the current framework of parallel health care systems. Multivariate analysis revealed that the birth order of the child was the key factor in d e t e r m i n i n g the n u m b e r of preventive visits, while the mother's perception of her child's health status held the major influence on the n u m b e r of curative visits. No association between utilization of services and social class was discovered. Comparison of utilization patterns arising from this study with subsequent investigation of the planned integrated services allows for the assessment of the effects of a major change in the structure and delivery of pediatric services.
H. Pahi is Associate Professor, Head of Maternal and Child Health Unit, Department of Social Medicine, Hadassah Medical Organization, and Director, School of Public Health and Community Medicine, Hebrew University-Hadassah; Y. Neumark is instructor at the School of Public Health and Community Medicine, Hebrew University-Hadassah; M. Donchin is a member of the Department of Social Medicine, Hadassah Medical Organization; A.Y. Ellencweig is a member of the Department of Medical Ecology, Hebrew University-Hadassah. Acknowledgement: The research on "Utilisation of health services" was supported by Hadassah Medical Organisation, The Jerusalem Municipality, the Ministry of Health and the Labour Sick Fund. It is the first in a series of papers on the utilisation of health services. Part of this publication is based on the MPH thesis of Y. Neumark tutored by H. Palti. Requests for reprints should be addressed to: Dr. Hava Palti, School of Public Health & Community Medicine, P.O. Box 1172, Jerusalem 91010, Israel. © 1992 Human Sciences Press, Inc.
271
272
JOURNAL OF COMMUNITY HEALTH
INTRODUCTION
Child health care is concerned with the prevention of disease, the early detection of problems effecting growth and development, the promotion of health, the treatment of acute and chronic disease and rehabilitation. In Israel, these health care components are addressed by two different health services systems. Historically, preventive and promotive health care for pregnant women and children was established in 1912, with the aim of reducing malnutrition and infant mortality among the poor residents of the City of Jerusalem. j From these first initiatives grew a national network of preventive services--the Family Health Centers (FHC). Today, 98% percent of the infant population in Israel is registered and receives care at the FHC in their area of residence? As these services are provided free of charge (only a symbolic sum is paid by the care recipient) the FHCs are available and accessible to all. These preventive services were already well established when the Labour Union organized medical insurance for its members and established their Sick Fund, which provides ambulatory and inpatient curative care services. Approximately 70 percent of the population of the country receives ambulatory curative care through the Labour Union's Sick Fund, with several smaller funds providing care to the rest of the population. All these funds operate along the lines of health maintenance organizations (HMOs). In the City of Jerusalem, preventive health care is provided to the entire population through 27 FHCs operated by the Municipality; 65 percent of the Jerusalem population is insured with the Labour Union's Sick Fund for curative care, while the rest of the population is insured by the other HMOs. Emergency services are provided by the 'Magen David Adom' (an equivalent of the Red Cross) and the four hospital emergency wards in the city. The existence of the two parallel services for infants, children and pregnant women (the FHCs and the sick funds), has led to the fragmentation of mother and child health care and a probable overuse of the health services. A survey in 1979 indicated that the average number of visits to the FHCs was 17 per child during the first year of life, while the 0-4 year olds made an average of 17.6 curative visits per year? The problem of over-utilization of services has only recently become a real issue in Israel, as rising health care costs have forced a reevaluation of the hitherto unquestioned social values and policies aimed at the achievement of optimal health and welfare of the entire population regardless of cost. As one means of reducing duplication of services and the resultant increased costs of care, the Ministry of Health recently
Hava Palti et al.
273
f o r w a r d e d the m o d e l o f i n t e g r a t e d curative a n d preventive pediatric services in a c o m p r e h e n s i v e health care setting. T h e p r e s e n t study was p l a n n e d to d e t e r m i n e the feasibility o f such a policy a n d its effects on the rates o f utilization, satisfaction a n d health o u t c o m e s within the pediatric population. This first p a p e r presents the baseline i n f o r m a t i o n , collected prior to c h a n g e s i n t r o d u c e d in the h e a l t h care system, a n d focuses on the utilization o f all the health services p r o v i d e d to the i n f a n t population o f J e r u s a l e m in 1988. It also d e f i n e s the characteristics o f the "high users" o f health services. METHODS
The study was conducted in five Jewish neighborhoods ill Jerusalem, each one containing an FHC and a curative clinic belonging to the Labour Union. The neighborhoods were selected to meet the objectives of" the evaluative study, such that following the collection of baseline information, two of the clinics are to be integrated and the other three will serve as control neighborhoods. The selected neighborhoods represent the inner city and suburban populations of upper, middle and middle-low social classes. None of the ultraorthodox (very religious) sections of the city were included. Population
The study population was comprised of the 955 single birth children born between December 1, 1985 and June 30, 1986, who were registered at the commencement of the study at "the local FHC in the five selected neighborhoods. As the FHCs receive direct notification of all births in the city, virtually every child born in Jerusalem is routinely registered in their local FHC. Six hundred and fifty one mothers were interviewed. High-mobility of young families within the city and between cities (12 percent-15 percent) creates a lag-time of about one year in the updating of the Municipality files, and as a result, 29 percent of the registered children were not reached. Less than 2% of those located refused to be interviewed. A questionnaire was prepared to collect information about the patterns of utilization of all health services during the first year of life, perceived health status of the child by the mother, compliance with prescribed health regimens, and satisfaction with the services. Interviews were carried out in the home when the child was one year of" age. The mean level of education of the mothers was 13.9 years (SD = 2.8) of schooling, slightly higher than that of the overall Jerusalem population. 4 Forty-three percent of the mothers categorized themselves as professionals. Forty-two percent were of Asian-African origin (as classified by mother's father's continent of birth), another 42 percent of Euro-American origin and 16 percent native Israeli. The mean age of the mothers was 31 years (SD = 5.1),
274
JOURNAL OF COMMUNITY HEALTH
with an average of 2.5 children per family (SD = 1.6). The national average is 2.7 children per family [2].
Statistical Analysis Univariate analysis was first performed to identify the individual determinants of utilization. ~ Analyses of variance were then performed to assess the unique contribution of each variable on the patterns of utilization while controlling for the possible confounding effects of various demographic and infant-related variables. In addition, a logit analysis was conducted in which the category of high utilizers was defined as the upper tenth percentile of the utilization distribution. The independent variables in the logit analysis were the same as those included in the analyses of variance.
RESULTS On the average, infants in the study population made slightly over 26 (26.14, s.d. = 13.9) visits to a pediatric health care provider during the first year of life. This included, 12.3 visits to the physician for curative care, 2.6 to the public health physician, 8.5 to the public health nurse, and 2.7 visits to all other care providers (including emergency wards, hospitalizations, first-aid stations, and child development centers).
Preventive and Ambulatory Curative Care Due to some differences in utilization patterns by the various d e m o g r a p h i c characteristics as revealed in the univariate analyses, and the differences in the population characteristics according to ethnic origin, analysis of variance was p e r f o r m e d on the n u m b e r of visits to the various health care providers, in o r d e r to control for possible confounding effects. T h e results of this analysis are presented in Table 1. As is evidenced in this table, when simultaneously controlling for the effects of mother's education and ethnic origin and infant's birthweight, the birth o r d e r of the infant is the only variable studied which shows a significant relationship with the utilization of preventive services (p < .0001), while the health status of the infant (as perceived by the mother) is the sole significant d e t e r m i n a n t of the level of curative services utilization (p < .0001). Visits to private physicians for ambulatory curative care (in addition or in place of visits to the ambulatory clinic of the insurance fund) were reported by 22 percent of mothers who perceived their infant to be in poor health, c o m p a r e d with 13% of mothers with 'healthy' infants (.01 < p < .05).
Hava Palti et al.
275
TABLE 1
Mean N u m b e r o f Visits to Preventive a n d Curative Services by D e m o g r a p h i c a n d Health Characteristics-Analysis Variance
Factor Total Health status o f i n f a n t good poor
Preventive Services Adjusted N Mean 595
11.20
477 118
11.3 10.9
B
P
.03
ns
.24
.000
.06
ns
.01
ns
.07 R = .065
ns
.000
.28
.000
.07
.095
N u m b e r of children one two +
Maternal education 0-11 years 12+ years Maternal ethnicity Asia/Africa Euro/Israel Birthweight < 2 5 0 0 gr. 2500 + gr.
169 426
93 502
255 340
33 562
13.1 10.5
11.9 I 1.1
11.3 I 1.1
12.5 11.1
Curative Services Total Health status o f infant good poor N u m b e r o f children one two +
573 461 112
166 407
8.69 7.4 14.0
7.1 9.1
276
JOURNAL
OF COMMUNITY
HEALTH
TABLE 1 (Continued)
Preventive Services Adjusted N Mean
Factor Maternal education 0-11 years 12 + years Maternal ethnicity Asia/Africa Euro/Israel Birthweight < 2 5 0 0 gr. 2 5 0 0 + gr.
86 487
239 334
33 540
B
P
9.1 8.6 .02
ns
.04
ns
9.1 8.4
8.8 8.7 .00 R = .097
ns .000
*ns = not significant.
Hospitalization Overall, 16 percent of respondents reported that their infant had been hospitalized within the first year of life, while nearly 4 p e r c e n t r e p o r t e d two hospitalizations, a n d 1 percent r e p o r t e d three or m o r e hospitalizations. T h e two i n d e p e n d e n t variables with which hospitalization o f the infant showed a significant association were the presence or absence o f a chronic disorder in the infant (chi square = 29.8, p < .0001, O.R. = 3.6), a n d the m o t h e r ' s perception o f her child's health status (chi s q u a r e = 15.2, p < .0001, O.R. = 2.6).
Emergency Room Visits O n the average, 2.3 visits were m a d e to an e m e r g e n c y r o o m during the first year o f life (s.d.=4.1). Multi-variate analysis revealed that the presence o f a chronic disorder in the infant, the mother's percep-
H a v a Palti et a l .
277
TABLE 2
Determinants of High Utilization of Health Services by Demographic and Health Characteristics Expressed as Odds Ratios-Log Linear Analysis
Variable
Categories
Child's Health: N u m b e r Children: Mom's Education: Birthweight: Mom's Ethnicity: n
poor vs. good 1 vs. 2 +
UTILIZATION OF PEDIATRIC HEALTH SERVICES IN JERUSALEM Yehuda Neumark, MPH; Hava Pahi, MD, MPH; Milka Donchin, MD, MPH; Avi-Yacar Ellencweig, PhD, MPH, MBA
ABSTRACT: T h e high rate of utilization of health services and rising health care costs in Israel, have prompted the need for refi)rm of the health care system. Preventive and curative aspects of mother and child health care in Israel have traditionally been addressed by indep e n d e n t but parallel health systems. Prior to the pilot integration of these services, current patterns of utilization of health services by children d u r i n g their first year of life, and determinants of use, were analyzed. Mothers of 651 children from five neighborhoods, representing the middle-low, middle and upper social class Jewish population were interviewed. Overall, a high degree of compliance with reco m m e n d e d visits to the preventive family health centers was found, with an average of eleven visits to the public health physician or nurse. The children also made an average of 12 visits to curative practitioners. Combined with all other health care consuhations, these children averaged 26 health care visits in the first year of life. This pattern of frequent visitations, and its determinants, is discussed in context of the current framework of parallel health care systems. Multivariate analysis revealed that the birth order of the child was the key factor in d e t e r m i n i n g the n u m b e r of preventive visits, while the mother's perception of her child's health status held the major influence on the n u m b e r of curative visits. No association between utilization of services and social class was discovered. Comparison of utilization patterns arising from this study with subsequent investigation of the planned integrated services allows for the assessment of the effects of a major change in the structure and delivery of pediatric services.
H. Pahi is Associate Professor, Head of Maternal and Child Health Unit, Department of Social Medicine, Hadassah Medical Organization, and Director, School of Public Health and Community Medicine, Hebrew University-Hadassah; Y. Neumark is instructor at the School of Public Health and Community Medicine, Hebrew University-Hadassah; M. Donchin is a member of the Department of Social Medicine, Hadassah Medical Organization; A.Y. Ellencweig is a member of the Department of Medical Ecology, Hebrew University-Hadassah. Acknowledgement: The research on "Utilisation of health services" was supported by Hadassah Medical Organisation, The Jerusalem Municipality, the Ministry of Health and the Labour Sick Fund. It is the first in a series of papers on the utilisation of health services. Part of this publication is based on the MPH thesis of Y. Neumark tutored by H. Palti. Requests for reprints should be addressed to: Dr. Hava Palti, School of Public Health & Community Medicine, P.O. Box 1172, Jerusalem 91010, Israel. © 1992 Human Sciences Press, Inc.
271
272
JOURNAL OF COMMUNITY HEALTH
INTRODUCTION
Child health care is concerned with the prevention of disease, the early detection of problems effecting growth and development, the promotion of health, the treatment of acute and chronic disease and rehabilitation. In Israel, these health care components are addressed by two different health services systems. Historically, preventive and promotive health care for pregnant women and children was established in 1912, with the aim of reducing malnutrition and infant mortality among the poor residents of the City of Jerusalem. j From these first initiatives grew a national network of preventive services--the Family Health Centers (FHC). Today, 98% percent of the infant population in Israel is registered and receives care at the FHC in their area of residence? As these services are provided free of charge (only a symbolic sum is paid by the care recipient) the FHCs are available and accessible to all. These preventive services were already well established when the Labour Union organized medical insurance for its members and established their Sick Fund, which provides ambulatory and inpatient curative care services. Approximately 70 percent of the population of the country receives ambulatory curative care through the Labour Union's Sick Fund, with several smaller funds providing care to the rest of the population. All these funds operate along the lines of health maintenance organizations (HMOs). In the City of Jerusalem, preventive health care is provided to the entire population through 27 FHCs operated by the Municipality; 65 percent of the Jerusalem population is insured with the Labour Union's Sick Fund for curative care, while the rest of the population is insured by the other HMOs. Emergency services are provided by the 'Magen David Adom' (an equivalent of the Red Cross) and the four hospital emergency wards in the city. The existence of the two parallel services for infants, children and pregnant women (the FHCs and the sick funds), has led to the fragmentation of mother and child health care and a probable overuse of the health services. A survey in 1979 indicated that the average number of visits to the FHCs was 17 per child during the first year of life, while the 0-4 year olds made an average of 17.6 curative visits per year? The problem of over-utilization of services has only recently become a real issue in Israel, as rising health care costs have forced a reevaluation of the hitherto unquestioned social values and policies aimed at the achievement of optimal health and welfare of the entire population regardless of cost. As one means of reducing duplication of services and the resultant increased costs of care, the Ministry of Health recently
Hava Palti et al.
273
f o r w a r d e d the m o d e l o f i n t e g r a t e d curative a n d preventive pediatric services in a c o m p r e h e n s i v e health care setting. T h e p r e s e n t study was p l a n n e d to d e t e r m i n e the feasibility o f such a policy a n d its effects on the rates o f utilization, satisfaction a n d health o u t c o m e s within the pediatric population. This first p a p e r presents the baseline i n f o r m a t i o n , collected prior to c h a n g e s i n t r o d u c e d in the h e a l t h care system, a n d focuses on the utilization o f all the health services p r o v i d e d to the i n f a n t population o f J e r u s a l e m in 1988. It also d e f i n e s the characteristics o f the "high users" o f health services. METHODS
The study was conducted in five Jewish neighborhoods ill Jerusalem, each one containing an FHC and a curative clinic belonging to the Labour Union. The neighborhoods were selected to meet the objectives of" the evaluative study, such that following the collection of baseline information, two of the clinics are to be integrated and the other three will serve as control neighborhoods. The selected neighborhoods represent the inner city and suburban populations of upper, middle and middle-low social classes. None of the ultraorthodox (very religious) sections of the city were included. Population
The study population was comprised of the 955 single birth children born between December 1, 1985 and June 30, 1986, who were registered at the commencement of the study at "the local FHC in the five selected neighborhoods. As the FHCs receive direct notification of all births in the city, virtually every child born in Jerusalem is routinely registered in their local FHC. Six hundred and fifty one mothers were interviewed. High-mobility of young families within the city and between cities (12 percent-15 percent) creates a lag-time of about one year in the updating of the Municipality files, and as a result, 29 percent of the registered children were not reached. Less than 2% of those located refused to be interviewed. A questionnaire was prepared to collect information about the patterns of utilization of all health services during the first year of life, perceived health status of the child by the mother, compliance with prescribed health regimens, and satisfaction with the services. Interviews were carried out in the home when the child was one year of" age. The mean level of education of the mothers was 13.9 years (SD = 2.8) of schooling, slightly higher than that of the overall Jerusalem population. 4 Forty-three percent of the mothers categorized themselves as professionals. Forty-two percent were of Asian-African origin (as classified by mother's father's continent of birth), another 42 percent of Euro-American origin and 16 percent native Israeli. The mean age of the mothers was 31 years (SD = 5.1),
274
JOURNAL OF COMMUNITY HEALTH
with an average of 2.5 children per family (SD = 1.6). The national average is 2.7 children per family [2].
Statistical Analysis Univariate analysis was first performed to identify the individual determinants of utilization. ~ Analyses of variance were then performed to assess the unique contribution of each variable on the patterns of utilization while controlling for the possible confounding effects of various demographic and infant-related variables. In addition, a logit analysis was conducted in which the category of high utilizers was defined as the upper tenth percentile of the utilization distribution. The independent variables in the logit analysis were the same as those included in the analyses of variance.
RESULTS On the average, infants in the study population made slightly over 26 (26.14, s.d. = 13.9) visits to a pediatric health care provider during the first year of life. This included, 12.3 visits to the physician for curative care, 2.6 to the public health physician, 8.5 to the public health nurse, and 2.7 visits to all other care providers (including emergency wards, hospitalizations, first-aid stations, and child development centers).
Preventive and Ambulatory Curative Care Due to some differences in utilization patterns by the various d e m o g r a p h i c characteristics as revealed in the univariate analyses, and the differences in the population characteristics according to ethnic origin, analysis of variance was p e r f o r m e d on the n u m b e r of visits to the various health care providers, in o r d e r to control for possible confounding effects. T h e results of this analysis are presented in Table 1. As is evidenced in this table, when simultaneously controlling for the effects of mother's education and ethnic origin and infant's birthweight, the birth o r d e r of the infant is the only variable studied which shows a significant relationship with the utilization of preventive services (p < .0001), while the health status of the infant (as perceived by the mother) is the sole significant d e t e r m i n a n t of the level of curative services utilization (p < .0001). Visits to private physicians for ambulatory curative care (in addition or in place of visits to the ambulatory clinic of the insurance fund) were reported by 22 percent of mothers who perceived their infant to be in poor health, c o m p a r e d with 13% of mothers with 'healthy' infants (.01 < p < .05).
Hava Palti et al.
275
TABLE 1
Mean N u m b e r o f Visits to Preventive a n d Curative Services by D e m o g r a p h i c a n d Health Characteristics-Analysis Variance
Factor Total Health status o f i n f a n t good poor
Preventive Services Adjusted N Mean 595
11.20
477 118
11.3 10.9
B
P
.03
ns
.24
.000
.06
ns
.01
ns
.07 R = .065
ns
.000
.28
.000
.07
.095
N u m b e r of children one two +
Maternal education 0-11 years 12+ years Maternal ethnicity Asia/Africa Euro/Israel Birthweight < 2 5 0 0 gr. 2500 + gr.
169 426
93 502
255 340
33 562
13.1 10.5
11.9 I 1.1
11.3 I 1.1
12.5 11.1
Curative Services Total Health status o f infant good poor N u m b e r o f children one two +
573 461 112
166 407
8.69 7.4 14.0
7.1 9.1
276
JOURNAL
OF COMMUNITY
HEALTH
TABLE 1 (Continued)
Preventive Services Adjusted N Mean
Factor Maternal education 0-11 years 12 + years Maternal ethnicity Asia/Africa Euro/Israel Birthweight < 2 5 0 0 gr. 2 5 0 0 + gr.
86 487
239 334
33 540
B
P
9.1 8.6 .02
ns
.04
ns
9.1 8.4
8.8 8.7 .00 R = .097
ns .000
*ns = not significant.
Hospitalization Overall, 16 percent of respondents reported that their infant had been hospitalized within the first year of life, while nearly 4 p e r c e n t r e p o r t e d two hospitalizations, a n d 1 percent r e p o r t e d three or m o r e hospitalizations. T h e two i n d e p e n d e n t variables with which hospitalization o f the infant showed a significant association were the presence or absence o f a chronic disorder in the infant (chi square = 29.8, p < .0001, O.R. = 3.6), a n d the m o t h e r ' s perception o f her child's health status (chi s q u a r e = 15.2, p < .0001, O.R. = 2.6).
Emergency Room Visits O n the average, 2.3 visits were m a d e to an e m e r g e n c y r o o m during the first year o f life (s.d.=4.1). Multi-variate analysis revealed that the presence o f a chronic disorder in the infant, the mother's percep-
H a v a Palti et a l .
277
TABLE 2
Determinants of High Utilization of Health Services by Demographic and Health Characteristics Expressed as Odds Ratios-Log Linear Analysis
Variable
Categories
Child's Health: N u m b e r Children: Mom's Education: Birthweight: Mom's Ethnicity: n
poor vs. good 1 vs. 2 +
