Subjective unmet need and utilization of health care services in Canada: What are the equity implications?
Introduction
Most health systems in high-income countries endorse equity goals in terms of ensuring access to needed health care irrespective of socioeconomic status. One widely used method for measuring inequity is to determine whether factors other than need for health care affect health care utilization (Aday and Andersen, 1974, Aday and Andersen, 1981). Inequity then arises, for example, when individuals in higher socioeconomic groups are more likely to use, or are using a greater quantity of, health services after controlling for their level of ill-health than those in lower socioeconomic groups. This conventional method of measuring socioeconomic inequity based on needs-adjusted utilization is limited for at least three reasons. First, differences in needs-adjusted utilization patterns by socioeconomic status may not necessarily imply inequity because these differences may be explained in part by individuals’ informed choices and preferences (Le Grand, 1991). Second, utilization is usually measured as visit rates, so an apparently equal distribution of needs-adjusted utilization by socioeconomic status may not be equitable if the services being used are of low quality, or are inappropriate (Thiede, Akweongo, & McIntyre, 2007). Third, conventional methods rely on measures of ill-health, which may not adequately measure need for health care.
In light of these limitations with the conventional method of measuring socioeconomic inequity, the direct measurement of “unmet need”, or any need for health care that remains because appropriate health care was not received, may complement the conventional method and address some of its limitations. There are two possible approaches to measuring unmet need in a population: “clinical” or “subjective”. The former relies on a clinical assessment of whether an individual did not receive appropriate care (Carr & Wolfe, 1976), the definition of appropriate being based on clinical guidelines and, as a result, specific to a narrow set of conditions and treatments. The latter relies on individuals’ subjective assessments that they have not received the care that they need. The latter approach is more feasible because numerous existing surveys include questions pertaining to unmet need; it is also in some ways superior since arguably individuals are better able to estimate their health status (Idler & Benyamini, 1997), as well as being in a unique position to identify shortcomings in their experiences with health care. Physicians have imperfect information about patients’ health care needs so they rely on patients’ communication of symptoms and history in order to make treatment decisions (Balsa & McGuire, 2001). Therefore, minority and lower socioeconomic groups may receive less effective services because of the poorer quality of communication among patients with different socioeconomic and ethnic backgrounds from their physicians (Balsa and McGuire, 2001, Balsa and McGuire, 2003); experiences that may be perceived as unmet need by the patients. Subjective assessments of unmet need may also include information on the reasons for the unmet need, which can then be used to focus policy actions.
This study examines the relationship between subjective unmet need (SUN) for health care and the conventional method of measuring socioeconomic inequity based on needs-adjusted utilization. The study has three objectives. First, we draw existing work together to establish meaningful definitions of unmet need, with a focus on how SUN differs from the conventional method of measuring inequity. Second, we examine the relationship between different types of SUN and health care utilization, and third, we assess the contribution of unmet need to estimates of income-related inequity in health care utilization. The paper's next section proposes a conceptual framework of unmet need, followed by a review of the literature and a discussion of the relationship between unmet need, utilization and equity. The data and methods are reviewed in the following sections, and the results are presented and discussed in the final sections.
Section snippets
Conceptualizing unmet need
Need for health care is an elusive concept that is difficult to define and measure. However, the definition of need commanding the widest approval is that it measures the care that is required to bring about the maximum possible health improvement within given resource constraints (Culyer and Wagstaff, 1993, Folland et al., 2004, Stevens and Gillam, 1998). Unmet need therefore arises when an individual does not receive an available and effective treatment that could have improved her health;
Existing research on subjective unmet need
To date research on SUN has focused on measuring its prevalence and investigating its individual- and system-level predictors. Most studies have presumed that SUN represents access barriers (as in Category 3 above), and indeed many survey questions are phrased in order to measure that SUN which arises through access barriers such as costs. Most studies do not disaggregate analyses of unmet need into the different categories, although, as we will go on to argue, a disaggregated approach is
Unmet need, utilization and equity
From the above review of the literature it appears that the relationship between SUN and utilization depends upon how SUN is defined, upon the framing of the questions, and upon the possible reasons for unmet need that are included. Previous utilization among individuals who report any unmet need, which was shown in some studies, is expected given they are in poorer health. One would expect, and studies of cost-related unmet need suggest, that after adequately controlling for ill-health, there
Methods
Our analysis investigates the association between SUN and utilization, and then measures the effect of including SUN into needs-adjustment on the estimates of income-related inequity. The association between SUN and utilization is estimated first by modeling the probability and then intensity of use on a comprehensive set of needs-related and socioeconomic factors, in addition to the different types of SUN. To obtain the need-predicted utilization, the non-need (and SUN) variables were held
Data and variables
This study is based on the 2003 CCHS conducted by Statistics Canada. It is a biennial, cross-sectional, community-based population health survey based on a multi-stage clustered design with individual occupants of private occupied dwellings as the final sampling unit. For this study, the three Territories were excluded due to under-sampling in these regions, and only the adult population aged 18 and over was included. The final sample included 97,828 adults aged 18 and above.
Descriptive statistics
Health status, socioeconomic characteristics, and utilization patterns vary across individuals who do not report any unmet need and across the different categories of unmet need (see Appendix 1). Women aged 18–34 make up a greater proportion of the sample with unmet needs (20%) than the total population (14%) and those without unmet needs (13%). Also, men in this youngest age category report more unmet need due to personal choice than among those with other types of unmet need and among those
Discussion
The direct measurement of unmet need for health care may complement conventional methods of measuring socioeconomic inequity in health care utilization because it provides information on individuals' subjective assessments of their experiences with health care. Conventional methods are limited because they do not account for variations in the quality and effectiveness of the care that is received, nor do they adjust for variations in utilization that are due to individuals' choices or
Acknowledgements
We would like to thank Elias Mossialos, Walter Holland and Jerry Hurley for their helpful suggestions and insights. Thanks also to Li Wang for her assistance with the data analysis. This paper was written as part of Sara Allin's PhD thesis in Social Policy at the London School of Economics and Political Science.
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