Abstract
Objective
Direct measures of health care affordability from the user perspective are needed to monitor equitable access to publicly funded health care in Canada. The objective of our study was to develop a survey-based measure of health care affordability applicable to the Canadian context.
Methods
We developed items after focus group exploration of access and cost barriers in the health care trajectory. We administered an initial instrument by telephone to a randomly-selected sample of 750 respondents in metropolitan, rural, and remote settings in Quebec. After analysis we developed a new, self-administered version eliciting the frequency of problem access due to five affordability dimensions. This version was mailed to a subset of participants. We conducted exploratory and confirmatory factor analysis. We used ordinal logistic regression modelling to examine how individual items and the subscale score predicted indicators of difficult access. We looked for effect modification by income categories.
Results
The five items load on a single construct with good internal consistency (α = 0.77). The overall score, 0 to 5, reflects the sum of problems with health care affordability due to direct and indirect costs. The item and subscale scores are sensitive to income status, with affordability problems more prevalent among low-income than high-income respondents. Each unit increase in the subscale score predicts increased likelihood of unmet needs (OR = 1.54), emergency room use (OR = 1.41), and delay-related health problem aggravation (OR = 1.80).
Discussion
This subscale reliably and validly measures cost barriers to medically necessary services in Canada, and can potentially be applied in other settings with publicly funded health systems. It can be used to monitor and compare health care equity.
Key Words: Primary health care, accessibility of health services, Canada, health care disparities, outcome and process assessment (health care)
Résumé
Objectif
: La mesure directe de l’accessibilité économique des soins de santé du point de vue de l’utilisateur est nécessaire pour surveiller l’équité d’accès aux soins de santé financé publiquement. Notre objectif est de développer une mesure d’accessibilité financière des soins de santé applicable au contexte canadien.
Méthodes
Les items potentiels ont été développés à partir de résultats de groupes de discussion explorant les obstacles et facilitateurs de l’accès durant le processus de consommation des soins. La version initiale de l’instrument a été administrée par téléphone à un échantillon de 750 répondants sélectionné au hasard dans des régions métropolitaines, rurales et éloignées du Québec. Après analyse, une nouvelle version auto-administrée a été envoyée à un sous-ensemble de participants. L’échelle mesure la fréquence de problèmes d’accès selon cinq dimensions d’accessibilité économique. Nous avons effectué des analyses factorielles exploratoires et confirmatoires. Des modèles de régression logistique ordinale ont été utilisés pour examiner la capacité prédictive de chaque item et du score de la sous-échelle en terme de difficultés d’accès. Nous avons testé pour la modification de l’effet par catégorie de revenu.
Résultats
Les cinq items de la sous-échelle se regroupent sur un seul facteur qui démontre une bonne cohérence interne (α = 0,77). Le score global, de 0 à 5, reflète la somme des problèmes d’accessibilité économique des soins de santé en raison des couts directs et indirects. Le score est sensible au statut économique des répondants, les problèmes d’accessibilité économique étant plus répandus chez les répondants ayant un faible revenu. Un accroissement du score de la sous-échelle prédit une propension accrue à déclarer des besoins non comblés (RC = 1,54), l’utilisation de soins d’urgence (RC = 1,41), et une aggravation de problèmes de santé due à des délais d’accès (RC = 1,80).
Discussion
Cette sous-échelle mesure de manière fiable et valide des obstacles économiques aux services médicalement nécessaires dans le système de santé canadien. Elle pourrait potentiellement être appliquée dans d’autres pays ayant des soins de santé financés par l’État. Il peut être utilisé pour surveiller et comparer l’équité des soins de santé.
Mots Clés: soins de santé, primaires, accessibilité, aux services de santé; Canada, disparités en soins de santé, évaluation des processus et résultats (soins de santé)
Footnotes
Acknowledgements: This study was funded by the Canadian Health Services Research Foundation (now Canadian Foundation for Health Improvement) and by the Centre de recherche de l’Hôpital Charles LeMoyne. We gratefully acknowledge Prof. Danièle Roberge, Université de Sherbrooke, who contributed to the conception and analysis of the qualitative study. Questionnaire preparation and field work were overseen by Christine Beaulieu and the statistical analyses were conducted by Fatima Bouharaoui.
Conflict of Interest: None to declare.
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