Health outcome disparities associated with access to primary care for vulnerable groups: Hospitalization for ambulatory care sensitive conditions

Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)


Public Administration


Douglas A. Wolf


Health outcome, Primary care, Hospitalization, Ambulatory care sensitive conditions

Subject Categories

Geriatrics | Health Policy | Health Services Administration | Race and Ethnicity


Eliminating health disparities is a federal and state policy goal. Accessible primary health care may reduce health disparities. Existing policies work to improve access by expanding insurance coverage, increasing physician supply in some areas, and enhancing physician workforce diversity. Hospitalization for Ambulatory Care Sensitive (ACS) conditions is an indicator of primary care access. This study examines associations between race, ethnicity, being a Medicaid recipient, or being uninsured, and ACS hospitalization. The study populations include working age adults and individuals age 65 or older. The 1997 Medical Expenditure Panel Survey, the 1997 Nationwide Inpatient Sample, and the U.S. Census are used to calculate rates of these hospitalizations. The sensitivity of these rates to degrees of physician discretion is investigated. These analyses are supplemented with estimates of the likelihood that a hospitalization will be for an ACS condition. The impact of state health policies that promote access is examined. The 1984-1990 Longitudinal Study of Aging (LSOA) and Medicare claims are used to identify hazards of ACS hospitalization for older individuals, focusing on disparities for nonwhites. The LSOA, linked with the 1984 National Health Interview Survey, is also used to examine associations between both physician supply and physician workforce diversity and the hazards of ACS hospitalization in urban areas. Methods used account for unmeasured heterogeneity. These methods include the Mantel-Haenszel chi-square, multilevel GLS and logistic analysis, and discrete time hazard models incorporating time-varying covariates, duration dependence measures, and random disturbance terms. The analyses consistently show that working age African Americans and Hispanics have significantly higher rates of ACS hospitalization than non-Hispanic whites. Older nonwhites have a significantly greater hazard of such hospitalizations than older whites. Medicaid recipients and the uninsured have significantly higher rates of these hospitalizations than the insured. These results indicate disparities in access to primary care. The policy analyses provide evidence that policies fostering access may reduce disparities. The analysis of physician supply suggests that areas with the fewest physicians have high rates of hospitalization for ACS conditions. Greater physician workforce diversity may be associated with reduced hazards of these hospitalizations for both whites and nonwhites.


Surface provides description only. Full text is available to ProQuest subscribers. Ask your Librarian for assistance.