Ontario
Child
Health
Study:
Patterns
of
Ambulatory
Medical
Care
Utilization
and Their
Correlates
Christel
A.
Woodward,
PhD,
Michael
H. Boyle,
MSc,
David
R. Offord,
MD,
David
T. Cadman,
MD,
Paul
S.
Links,
MD,
Heather
Munroe-Blum,
PhD,
Carolyn
Byrne,
RN,
MSc,
and
Helen
Thomas,
RN,
MSc
From the Child Epidemiology Unit, Department of Psychiatry, McMaster University Child
and Family Unit, Chedoke Division, Chedoke-McMaster Hospitals, Hamilton, Ontario,
Canada
ABSTRACT. Data from a large epidemiologic survey of
Ontario children 4 to 16 years of age are presented
concerning the frequency and correlates the use of am-bulatory medical care services during a 6-month period
in which a universal, first-dollar health insurance plan was used. Patterns of use of ambulatory medical care are described for three settings: doctor’s offices, emergency rooms, and hospital outpatient departments. A group of
children who are frequent users of ambulatory medical care (defined as using three or more services in 6 months) consumed nearly two thirds of all services. Two
regres-sion equations are presented-one predicting use/nonuse of ambulatory medical care and the other predicting the
total number of visits for medical care. Although only a
small proportion of the variance in use/nonuse and
amount of use was explained, the major determinant of both ambulatory medical care use and frequency of use
was the child’s physical health status as perceived by the parent. Younger child, urban area of residence, the num-ber of chronic medical problems of the child, and higher level of maternal education also contributed to the expla-nation of use v nonuse. Among ambulatory medical care
users, high users were more likely to be described as
having mental health problems and have parents who had been treated for “nerves.” Family size and socioeco-nomic variables were not important factors in use,
sug-gesting that universal health insurance reduces some barriers to ambulatory medical care for children. Pediat-rics 1988;82(pt 2): 425-434; ambulatory health care.
Research by Starfield et al”2 suggests that the patterns of ambulatory medical care among
chil-Received for publication Feb 23, 1987; accepted Oct 28, 1987. Reprint requests to (C.A.W.) Room 2C12 Health Sciences Centre, 1200 Main St W, McMaster University, Hamilton,
On-tario, Canada LSN 3Z5.
PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the
American Academy of Pediatrics.
dren may be consistent and stable. Children who have had large (or small) numbers of physician contacts in 1 year are more likely to have large (or small) numbers of physician contacts in the next year. Thus, it is important to isolate factors con-tributing to children’s use of ambulatory medical care and, particularly, those factors indicative of high rates of use. This can allow more rational planning of health care services for children and assist in ensuring that underserved children receive adequate health care.
health insurance alters the extent to which
socio-economic factors contribute to the explanation of ambulatory medical care use among children in an epidemiologic, community-based sample of Ontario
families with children 4 to 16 years of age.
Data already reported from the Ontario Child Health Study (OCHS)7 indicate that 59% of chil-dren in Ontario have had contact with one or more ambulatory medical care settings in the past 6 months. Lower rates of use were seen in rural compared with urban areas and among teenagers in contrast to younger children.
We examined in greater detail the use of ambu-latory medical care by a representative community-based sample of Ontario children who receive mcd-ical care provided by a universal, first-dollar health insurance plan. We studied the pattern of services provided within and across three delivery settings: physicians’ offices, emergency rooms, and hospital outpatient departments or clinics. A group of chil-dren was identified that accounts for a large pro-portion of total visits. These children were corn-pared with children who used ambulatory medical care services one or two times only. The explana-tory power of background variables to differentiate between nonusers and users of ambulatory medical care and to predict volume of use among users was evaluated in this community sample.
MATERIALS
AND
METHODS
Data from the OCHS, which was designed to estimate the prevalence of four psychiatric disor-ders among children 4 to 16 years of age in Ontario (the most populous of Canada’s ten provinces), were used in the present study. Only a brief summary of the OCHS design, including sampling and data collection procedures, is provided here; a more corn-plete description of the OCHS is presented else-where.8 The focus of this paper is the health status measures, utilization information, sociodemo-graphic variables, and analytic techniques relevant to describing ambulatory medical utilization and its correlates.
Summary of Survey Design
The target population of the study was all chil-dren living in Ontario between the ages of 4 and 16 years as of Jan 1, 1983. The sampling frame was the 1981 Census of Canada. Children living on Indian reservations, children who live in collective dwellings such as institutions, training schools, or mental health centres, and children living in dwell-ings that had been constructed since Census Day June 1, 1981, (3.3% of the target population) were
excluded from the frame. Sample selection was done by stratified, clustered, random sampling from the
census file of household dwellings. The province
was divided into the four administrative regions of the Ontario Ministry of Community and Social Services, and each region was divided into three strata based on population density: large urban
areas with more than 25,000 population; small ur-ban areas; and rural areas with less than 3,000 population. In large urban areas, a simple random sample was drawn within each region. A two-stage sampling procedure was used for small urban and rural areas to reduce the high cost of interviewer travel.
When an individual dwelling was selected for inclusion and located, households were screened by field staff to determine whether they contained an eligible child 4 to 6 years of age. Of the eligible households, 91% agreed to participate in the study. All household interviews were done by Statistics Canada field staff. These interviewers are employed by the federal government to collect data for the Census of Canada, the Canada Labor Force Survey, and other government statistical reports. In each family, one parent, usually the mother, and all children 12 to 16 years of age were interviewed.
Ambulatory
Medical
Care Utilization
Ambulatory medical care was defined as parental report that the child, 4 to 16 years of age, was the focal point of a consultation within the previous 6
months with staff of a hospital emergency room, a medical doctor’s office, or a hospital outpatient department or clinic. Mental health clinics use was
not included because, in Ontario, many children would not see a physician when visiting a mental
health clinic but rather be seen by a social worker or psychologist. Only 0.1% of children had been seen at a mental health clinic. The parent was also asked to recall the number of times services were sought from each service setting during the
preced-ing 6 months.
Data from the Canada Health Survey9 indicated that 28% of Canadian children do not have contact with a doctor during a 1-year period, whereas 48% have one or two contacts, and 24% have three or more contacts. To examine the bivariate
associa-tions of ambulatory medical care use with mdc-pendent variables, three groups were defined before data analysis: (1) nonusers were children who had not had ambulatory medical care contact in the
Child Health Status Measures
The conceptualization of health care utilization4
as a consequence of predisposing, enabling, and/or illness (need) variables of Andersen et a14 was used, and the following measures of need were selected
for study.
Need Variables
Physical Health. We derived four measures of the physical health status of children from the OCHS questionnaire.
A four-item scale closely adapted from the Rand Corporation Measure of Children’s Health for the Health Insurance Study’#{176}” was used to measure the parent’s perception of the child’s general phys-ical health. Parents evaluated whether the child’s health was excellent, whether he or she seemed to resist illness, whether the child seemed to be less healthy than other children they knew, and whether when something was “going around” the child usu-ally became ill. Responses were obtained on a five-point scale (from definitely true to definitely false) and were recorded so that a high score on each item reflected positive health. Scores could range from 4
to 20 on this general physical health perceptions scale.
The chronic medical condition measure was taken from a list of medical illnesses usually
long-term in duration (ie, heart problem, epilepsy or convulsions without fever, spina bifida, muscular
dystrophy or other muscle disease, and/or other problems [ie, missing limbs, a deformity, a condi-tion such as a club foot or cleft palate, paralysis or weakness of any kind, and/or chronic physical pain or discomfort], and/or problems of vision, hearing, or speech that were not entirely correctable). Over-all, 17.2% of children had one or more of these chronic medical conditions. The number of chronic
medical problems reported for 6 or more months’ duration was used in the analysis.
A child with chronic functional limitations was defined as one whose parent reported that for the past 6 months or more the child had experienced difficulty (beyond normal age-related expectations)
in one or more of the following ways: using
trans-portation or getting around the neighborhood;
abil-ity to walk unassisted; stooping, bending, lifting; walking several blocks or climbing a flight of stairs; needed help with self-care; was limited in vigorous
activities or the kind or amount of ordinary play or school work. The number of functional limitations reported was used. The measurement of both chronic medical conditions and functional limita-tions was similar to the method used by the health insurance study.’#{176}”
Children were also classified by whether or not they were reported to suffer from asthma or
hay-fever. These conditions were treated separately be-cause they occurred so frequently (18.5%) in our sample and might otherwise dominate the group of chronic medical conditions.
Mental Health. Two measures of the child’s men-tal health status were used. One was the parent’s perception of the child’s behavioral/emotional functioning, and the other involved an assessment
of specific child behaviors using a behavioral rating scale.8
Parents’ global report of mental health problems was derived from their answers to two questions: “during the past 6 months do you think your child has had any emotional or behavioral problems?” “During that time did (he/she) tend to have more emotional/behavioral problems than other (boys/ girls) of (his/her) age?” Only this latter group was used to define poor child mental health.
The second measure was taken from the Survey Diagnostic Instrument which is reported else-where.8 A subset of behavioral items related to conduct disorder and/or hyperactivity on the survey were considered to reflect externalizing behavioral problems. Another subset of items related to neu-rotic and/or somatizing behaviors and were consid-ered to reflect internalizing behavioral problems. Each item could be recorded as absent (0), some-times present (1), or usually present (2) by the parent. Twenty-one items were included on the externalizing scale (possible range of scores 0 to 42), and 25 items (0 to 50) made up the internalizing scale.
Predisposing/Enabling Variables
The OCHS contains a wealth of data about the participating children. For this analysis a subset of variables which seemed to be theoretically and em-pirically important candidates were included. These potential predisposing and enabling variables cho-sen are as follows.
Population Density. Urban: areas with a popula-tion density of 400/km2 or more. These included
1981 census metropolitan areas (having a popula-tion of more than 100,000) and census agglomera-tion (areas having a population of more than
25,00012). Rural: small towns, villages, farming corn-munities, and the rural fringe areas of census met-ropolitan and census agglomeration areas with a population density less than 400/km2.
last year and/or living in subsidized housing. Moth-er’s educational level: consisted of nine levels of educational attainment. Highest level of attain-ment achieved by the mother was classified as 9 (completed university or teachers college) and the lowest level was classified as 1 (no schooling). Low income: based on Statistics Canada’s definition which takes into account family size, income, and area of residence.” Single-parent household: only one parent in the home. Family dysfunction: family relations and parent health were measured by the general functioning scale, a 12-item subscale of the Family Assessment Device.’4 Scores could range from 12 to 48 and higher scores reflected greater dysfunction. Parental health problems: a parent has a chronic physical illness or physical disability. Parental mental health problems: a parent had been treated for “nerves” ever.
Statistical
Analysis
Estimates of use of physician services by the children of Ontario had been made using data weighted to reflect the underlying probability of entering the sample given the complex, multistage sampling procedure used.7 These weights were not used to examine potential correlates of utilization. Rather, the actual numbers were used in the anal-yses presented here. This was done to avoid the technical problems involved in determining statis-tical significance when sampling fractions are used to weight cases. Furthermore, weighing had no im-pact on the size of the estimates generated to meas-ure association between the variables.
We determined the degree to which children’s use of services showed evidence of familial aggre-gation by using a version of the Kstatistic described by Fleiss.’5 This statistic was interpreted as an intraclass correlation coefficient in which
between-household variance was compared to within-house-hold variance. A K value of 0 indicated no intrafa-milial clustering, and greater values indicate cvi-dence of clustering. Use of ambulatory care (K 0.37) exhibited substantial clustering within families. Given the observed clustering in use among chil-dren within a household, we randomly chose one child for each household participating in the study to examine patterns of use and correlates of these patterns (n = 1,869). Data loss occurred ifa variable
of interest was missing for the child selected (about
20% of cases had one or more missing variables). The first level of analysis was descriptive. To examine bivariate relationships between each in-dependent variable and use, either cross-tabula-tions or analysis of variance were used, depending on the format of the independent variable. Then,
we used the SSPS-X’6 statistical package for ordi-nary least squares regression analysis to evaluate
the importance of each possible explanatory van-able to utilization. This method allowed us to cx-amine the effect ofeach single variable independent of other variables in the model. Nine variables related to the child: age, sex, parents’ perception of general physical health, number of chronic health problems, number of chronic functional limitations, poor child mental health, number of externalizing behaviors, number of internalizing behaviors, and presence of hayfever/asthma. An additional eight potential explanatory variables described the household to which the child belonged: single par-ent, family dysfunction, parental health problems, parental mental health problems, population den-sity, low income, family size, and welfare/rent sub-sidy.
Two regression equations were developed: one equation was used to predict use or nonuse of ambulatory medical care during the course of the previous 6 months and the other equation was used to predict the amount of use for children with at least one physician contact during the same time. We chose to estimate the two equations separately because previous research has shown that some independent variables are better predictors of use/ nonuse than amount of use, whereas others are better predictors of volume of use.’7 Rather than using amount of use per se in the second equation, the log transformation of visit volume was used to reduce the distortion created by outlier physician visit observations. The same analytic (ordinary least squares regression) technique was used for both equations to allow direct comparison.
RESULTS
Use of Ambulatory
Medical
Care Services
Use of these services is summarized in the Figure. Overall, 58% of the children included in the present analysis had been the focal point of a consultation at one or more of the three settings in the previous 6 months. During the 6 months studied, these chil-dren used physicians’ services an average 1.56 times; this represented 2,748 visits. However, this mean utilization level is misleading because 42.1% of the children had no ambulatory medical care during the given 6-month period. A small group of children (17.8%, n = 313) had used ambulatory
medical care three or more times in the previous 6 months. These children, subsequently called fre-quent users, accounted for 66.1% of the services used.
Only 38.2% (n = 427) of the children in urban
com-Total: Ontario Urban Areas Small Urban/
Rural Areas TABLE 1. Service Use by User Groups by Type of
N Child,.”
1762
N ServIces
274
NChildren
1117
N Services
tUO
N Children N Services
645 559 Service Setting
100
90
80
70
60
50
40
30
20
10
0
Ch#{232}lden
:::Non-use,
R.giaN (1.2 tUne) use,
..: Frequent (3.,ime use’)
Figure. Ambulatory medical care service use by
popu-lation density.
pared with 48.8% (n 315) of children in small urban and rural areas. More urban children (19%, n = 212) than rural children (15.6%, n = 101) were
frequent users. Of the 859 services to rural children, 65.4% (562 services) were used by the 15.6% of children in the frequent user group (mean 5.56 services per frequent user). Similarly, urban fre-quent (19%) users consumed two thirds of the am-bulatory medical care services provided (1,259 of
1,889 services) in urban areas. The regular user group in both urban and rural areas consumed an average of 1.3 services during the 6 months.
Type of Ambulatory
Medical
Care Services
Used
As seen in Table 1, the majority of ambulatory medical care services were delivered in doctor’s offices (79.9%). Nearly 54% of all children visited a physician’s office during a 6-month period. A high proportion of both regular users (90.4%) and fre-quent users (98.7%) were seen in this setting. Fre-quent users (32.6% of children) consumed 65.4% of the total services delivered in doctor’s offices.
Emergency rooms were visited by 16% of children during a 6-month period, and these children ac-counted for 13.5% of the total ambulatory medical care use. Frequent users (despite their small num-bers, n = 313) were overrepresented in emergency
rooms; they made up 54.6% of emergency room users and accounted for 63.2% of the total emer-gency room contacts. Nearly half of the frequent users (49.2%) had emergency room contact as com-pared with 18.1% ofthe regular ambulatory medical care users.
During a 6-month period, 4.8% of the children visited hospital outpatient departments and clinics, and 6.8% of all ambulatory medical care services were provided at these settings. Again, frequent
Setting
Emergency
Room
Physician
Office
Hospital
Outpatient
Total No. of users 282 948 85
Total No. of contacts 370 2191 187
with service
% of total ambulatory 13.5 79.9 6.8
medical care use
% of all children 16.0 53.8 4.8
served
Regular users (n = 707)
% of group using serv- 18.1 90.4 4.2
ice
% of total users of 45.4 67.4 35.3
service
% of total contacts 36.7 34.6 17.1 Mean No. of visits per 1.1 1.2 1.1
user
Frequent users (n = 313)
% of group using serv- 49.2 98.7 17.6
ice
% of total users of 54.6 32.6 64.7
service
% of total contacts 63.2 65.4 82.9 Mean No. of visits per 1.5 4.6 2.8
user
users (17.6%) were more likely to use outpatient departments and clinics than regular users (4.2%) and made up 82.9% of the contacts. Most frequent users seen in the emergency room or hospital out-patient department or clinic also visited doctor’s offices during the 6-month period.
In summary, the group of frequent users of am-bulatory medical care services identified had a higher rate of contact in all three service settings. Moreover, this group consumed a disproportionate share of services across settings. The majority (87.2%) of the regular user group had visited only one service setting, usually a physician’s office (78.2%). Few frequent users had contact with only one setting (42.5%) and most had contact with at least two settings (49.5%). However, 41.5% had used only a doctor’s office.
Characteristics That Distinguish Among
Frequent,
Regular,
and Nonusers
of Ambulatory
Medical
Care Services
Within a 6-Month
Period
TABLE 2. Bivariate Assoc iations Bet ween Backgrou nd Charac teristics and Use r Status
Variable Definition Total Use Status x2 df P
Nonuser (n = 742)
Regular
user
(n = 707)
Frequent
user
(n = 313)
Hayfever/asthma % yes 18.5 12.9 18.7 31.2 48.70 2 .0000
Gender % boys 50.3 50.5 51.2 47.8 1.04 2 .5926
Perceived child mental
health (% more problem) 4.4 3.1 3.5 9.3 22.20 2 .0000
Single parent % yes 11.2 11.7 9.8 13.4 3.21 2 .2001
Urban % urban 63.4 57.5 67.6 67.7 18.88 2 .0001
Low income % yes 20.4 20.2 18.1 26.3 8.77 2 .0125
Welfare or rent subsidy % yes 8.5 8.7 7.0 11.3 5.14 2 .0765
Parent health problems % yes 30.3 27.9 28.9 39.3 14.43 2 .0007 Parent mental health % yes 22.3 20.5 19.0 27.2 29.63 2 .0000
problems
Urban children were overrepresented among users but the proportion of urban dwellers was similar for regular and frequent user groups. Children whose parents have chronic physical health prob-lems were more likely to be frequent ambulatory medical care users. A nonlinear relationship be-tween low income and ambulatory medical care use was seen, ie, children from low income families were underrepresented in the regular user group. Simi-larly, children from single-parent households and children whose families received welfare and/or subsidized housing were underrepresented in the regular user group. Children whose parents had a history of mental health contact (parent treated for “nerves”) were overrepresented in the frequent user group. Of the variables examined, only gender did not appear important to ambulatory medical care service use status.
Bivaniate association with ambulatory medical care use category was tested using analysis of van-ance techniques for variables that were formed by a scale or had an underlying continuous distnibu-tion. In each case, the procedure of Sheffe’8 was used to examine whether or not an individual group mean was significantly (P < .05) different from the others. These results are reported in Table 3.
The mean parent rating of the child’s overall physical health status was higher (better) among nonusers of ambulatory medical care. Nonusers also were significantly older than users and came from larger families and from families that reported a higher mean level of family dysfunctioning. On average, frequent users had more chronic medical problems and functional limitations than children who were regular or nonusers of services. As a group, frequent users were seen by their parents as being in poorer health and had more behaviors characteristic of children with internalizing and externalizing emotional disorders.
Least squares regression techniques were used to examine the individual contribution of each mdc-pendent variable to utilization. The results of the equations predicting user/nonuser status and amount of use among users are given in Table 4. Need is the feature most important to both use of ambulatory medical care services and volume of services consumed (the parent-reported general physical health perceptions scale and number of chronic medical problems of the child). No van-ables, except perceived need, played an important explanatory role in both regression equations. Age of the child, urban location, and mother’s educa-tional level were related to use/nonuse of ambula-tory medical cane services. A different set of predic-tons was found for amount of use. Here, both the parent’s perception of the child’s mental health and whether on not a parent had previous mental health contacts were also important explanatory variables.
DISCUSSION
The purpose of this analysis was to describe ambulatory medical care use among a community sample of children who reside in Ontario. In partic-ular, we examined the extent to which charactenis-tics of the child and his on her family influence utilization when paid for by a universal, first-dollar government-sponsored health insurance plan. Our data indicate that perceived need is the major de-tenminant of ambulatory medical care service use among children. However, the age of the child, size of the community in which he or she resides, and the educational level of the mother also independ-ently contribute to the explanation of use. Ambu-latory medical cane services may be more accessible to children in urban areas than to children in more sparsely populated areas where the population to
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5 frequency of ambulatory medical care use but only
to whether or not any use had occurred. The highest educational level of mothers was found in the group of children who had had one or two visits in the
!
previous 6 months.Despite the different health care context in On-tanio, our findings support earlier published studies of ambulatory medical care use by children in North
. America which indicate that health status of the
c child (need), however measured, is the single most
- important explanatory factor in use”2’5’6”92’ and - that use is correlated with the number of chronic
health problems the child has.5’2”22 Furthermore, many studies including ours, indicate that a small Z proportion of children consume a large quantity of
- the health services provided.”2”921’22 Our finding . that younger children are more likely to use health . services is also not unique.’9’20’23 The lack of
impon-tance of gender of the child as an explanatory variable has been reported repeatedly.20’23’24 A re-lationship between mother’s education and
physi-- cian use has also been observed previously.22’23’25’26 . The lack of explanatory power of socioeconomic
variables in the OCHS differs from other studies of
L correlates of ambulatory medical care use by North
American children.6”9’24’27 This OCHS finding
sug-‘ gests that the universal insurance provided by the
Ontario Health Insurance Plan has been effective in removing financial barriers to ambulatory mcd-ical care for Ontario’s children. Neither income below the poverty level nor receiving social
assist-. ance payments and/or subsidized rent entered
either regression equation. However, bivariate
anal-. yses suggested that children from such families
. were underrepresented among regular users and
g overrepresented among frequent users, whereas the
. proportion of nonusers was similar to the overall
group. This is not surprising given the low (r < .11) but significant association of these socioeconomic
Cl) variables with poorer health status and number of
chronic medical problems among children within the data set. Similarly, several reports in the literature2226 indicate that children from small families are more likely to receive medical cane than children from larger families. This association was
. also noted in our bivaniate analyses but failed to
enter either equation. Among the children studied,
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TABLE 4. Estimated Regression Coefficient for Predicting Effects of Child and Family
Features on Log Volume of Ambulatory Medical Care Services and on Use/Nonuse
Use/Nonuse (n = 1,412) Log Volume (n = 832)
B9 /3t t B9 i3t t
Constant 1.052 10.96 1.72 11.42
General physical health -0.027 -0.147 -5.49 -0.070 -0.273 -8.16
scale
Age -0.019 -0.145 -5.57
Urban 0.104 0.102 3.99
Chronic medical conch- 0.072 0.083 3.14 0.132 0.116 3.34 tion
Mother’s educational 0.021 0.083 3.18
level
Parent mental health 0.157 0.090 2.74
Perceived child mental 0.316 0.090 2.70
health
Adjusted R2 0.075 0.136
Fvalue 23.98 33.84
Pvalue 0 0
* Unstandardized partial regression coefficient.
t Standardized partial regression coefficient.
contribution to predicting ambulatory medical care use or amount of use when other factors were taken into account in the analysis. Again, this difference may be related to reducing barriers to care through the universal health insurance plan.
There is a growing literature that suggests that parental, especially maternal, factors are important to health care utilization by children.5’6”9’20’2326’ Particularly, several investigators have suggested that stressed mothers are more likely to seek mcd-ical care for their children and that children of such mothers are overnepresented among frequent users.5’20’23’29’3#{176}Each study has defined stress some-what differently. The OCHS variable closest to this concept is “parental treatment for ‘nerves,’ “
mdi-cating that either or both parents have sought help for mental health problems in the past. It is then not surprising that this variable enters the regres-sion equation predicting increased service use. However, it is not clear whether these parents alter their perceptions of the child based on their own needs or whether their mental health problems directly interfere with their children’s health.
Some limitations in our data and analytic
strat-egy should be acknowledged. We made no allow-ances for sampling design effects in these analyses. We do not think decisions introduced significant distortion in our findings. It should also be noted that the questions posed to the respondent made no distinction between indirectly consulting a phy-sician (eg, via telephone or without the child) and an actual visit by the child to receive medical treat-ment. However, the vast majority of consultations are likely to have been direct visits. Furthermore, whether use was initiated by the parent on the
child’s behalf, the child him- or herself (particularly
adolescents), or the physician was not ascertained. Use could be for preventive or curative purposes and these uses were not differentiated. Finally, some recall bias may have occurred if respondents with particular characteristics were more likely to underreport on overstate the number of times am-bulatory medical care services were used. Cleary and Jette,3’ who compared self-reported and actual utilization for adults, indicated that the average error in self-reported utilization among adults is small (using a 12-month recall period), although there is a tendency for high users to underreport their use. The likelihood that explanatory variables are related to a reporting bias of the informant rather than ambulatory medical care use is small. However, we cannot assess whether bias exists or the extent of bias within the data set.
cx-plained.19 These observations remain true whether service use is measured by parental retrospective
report’9’21 or by prospective gatherings of actual use
data”20’23 and affect only episodic illness use2#{176}or all use.’9 A somewhat stronger association with
back-ground variables (29% ofvariance in use explained)
is seen when children’s utilization histories are examined throughout long periods (ie, 6 years)2. However, it is not clear how much the length of time use was studied and/or the special features of the group (limited group of providers and little
geographic mobility) independently contribute to the increase in explanatory power observed.
Among the children studied, 70% of children
whose parents thought that their child had more mental health problems than their peers were seen in ambulatory medical care services compared with 57% of those children without mental health prob-lems. Parental perception of poor mental health in the child is important in explaining increased
fre-quency of ambulatory medical cane among users. Of the children whose parents identified them as hay-ing more emotional and behavioral problems than their peers, 38% were found in the frequent user group, whereas only 16.8% of children not so iden-tified were frequent users. Other investi-gators2’22’34’35 have also reported increased use of medical services by children with emotional and behavioral problems. However, in the OCHS, pre-vious analyses indicate that no difference was ob-served in ambulatory medical care use for children categorized by Survey Diagnostic Instrument cni-tenia has having one or more of four psychiatric disorders: hyperactivity, conduct disorder, emo-tional disorder and/or somatization.7 This suggests that a parent may indicate that his or her child
displays many problem behaviors without recogniz-ing that children with the number and/or type of behavior displayed would be labeled by externally applied criteria as having significant emotional problems. Many children with Survey Diagnostic Instrument-diagnosed psychiatric problems were not perceived by their parents as having more emo-tional/behavioral problems than their peers. These children are not overrepresented among ambula-tory medical care users. Parental perception of mental health difficulties in the child thus appears to be important to initiating ambulatory medical care contact for such children.
SUMMARY
AND
IMPLICATIONS
Universal, first-dollar health insurance available to families in Ontario seems to have reduced socio-economic barriers to medical care. Poor economic circumstances and family size are not related to
use/nonuse of ambulatory medical care services. However, some barriers to care remain for the ambulatory medical care of Ontario. Continued ef-fonts must be made to encourage less educated women to seek regular cane for their children. Sim-ilarly, the inequities in the population to physician
ratios between rural and urban areas in Ontario translate into reduced likelihood of physician con-tact among children in rural areas. Younger chil-dren are more likely to receive regular ambulatory medical care than older children. Whether this is appropriate is not clear. A major concern for health planning is that better explanatory power is seen in models predicting volume of use than whether or not ambulatory medical care services are used or not used by children. Among users, children with psychosocial problems and chronic medical condi-tions are more likely to be frequent users. These findings support previous suggestions”2 that phy-sicians must be sensitive to potential psychosocial difficulties in children who are frequent users of ambulatory medical care services. The central role of the parent’s perceptions of their child (both in
terms of physical and mental health) in seeking ambulatory medical care services is again high-lighted.
ACKNOWLEDGMENTS
The Ontario Child Health Study was supported by the
Ministry of Community and Social Services of Ontario. Dr Cadman is supported by a Career Health Scientist Award of the Ontario Ministry of Health; M. H. Boyle
was supported by a National Health and Welfare
Re-search Fellowship during his work on this project. We acknowledge the essential contribution of H. Hoff-man and G. Catlin of Statistics Canada in the design and data collection of the study. Dr Harry Shannon provided
statistical advice.
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