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Andrew B. Bindman, MD; Kevin Grumbach, MD; Dennis Osmond, PhD; Miriam Komaromy, MD; Karen Vranizan, MA; Nicole Lurie, MD, MSPH; John Billings, JD; Anita Stewart, PhD

JAMA. 1995;274(4):305-311.

Abstract
Objective.
—To examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style.

Design.
—Analysis of California hospital discharge data. We calculated the hospitalization rates for these five chronic conditions for the 250 ZIP code clusters that define urban California. We performed a random-digit telephone survey among adults residing in a random sample of 41 of these urban ZIP code clusters stratified by admission rates and a mailed survey of generalist and emergency physicians who practiced in the same 41 areas.

Setting.
—Community based.

Participants.
—A total of 6674 English- and Spanish-speaking adults aged 18 through 64 years residing in the 41 areas were asked about their access to care, their chronic medical conditions, and their propensity to seek health care. Physician admitting style was measured with written clinical vignettes among 723 generalist and emergency physicians practicing in the same communities.

Main Outcome Measures.
—We compared respondents' reports of access to medical care in an area with the area's cumulative admission rate for these five chronic conditions. We then tested whether access to medical care remained independently associated with preventable hospitalization rates after controlling for the prevalence of the conditions, health care seeking, and physician practice style.

Results.
—Access to care was inversely associated with the hospitalization rates for the five chronic medical conditions (R²=0.50; P<.001). In a multivariate analysis that included a measure of access, the prevalence of conditions, health care seeking, and physician practice style to predict cumulative hospitalization rates for chronic medical conditions, both self-rated access to care (P<.002) and the prevalence of the conditions (P<.03) remained independent predictors.

Conclusion.
—Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions.

(JAMA. 1995;274:305-311)

Author Affiliations
From the Primary Care Research Center (Drs Bindman, Grumbach, Osmond, and Komaromy and Ms Vranizan) and Division of General Internal Medicine (Dr Bindman and Ms Vranizan), San Francisco (Calif) General Hospital; Departments of Medicine (Dr Bindman and Ms Vranizan), Epidemiology and Biostatistics (Drs Bindman and Osmond), and Family and Community Medicine (Dr Grumbach), Institute for Health Policy Studies (Drs Bindman and Grumbach), Division of General Internal Medicine (Dr Komaromy), and Institute for Health and Aging (Dr Stewart), University of California, San Francisco; Department of Medicine, Hennepin County Medical Center, University of Minnesota Schools of Medicine and Public Health, Minneapolis (Dr Lurie); and Robert F. Wagner Graduate School of Public Service, New York (NY) University (Mr Billings).

Footnotes
Reprint requests to Primary Care Research Center, San Francisco General Hospital, Ward 95, 1001 Potrero Ave, San Francisco, CA 94110 (Dr Bindman).

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