Explanatory Power of the Behavior Model of Utilization for Pediatric Asthma Health Care in an Urban Managed Care Setting

The Behavior Model o f Utilization played a key role in explaining health services use for pediatric members with asthma in one urban, regional managed care company. The critical role die asthma management program played in promoting the health and well-being of enrolled members was elucidated Information gleaned from this empirical study can be used to encourage appropriate resource utilization, formulate pediatric asthma health policy, and deliver cost-effective, quality health care. More importantly, managed care company administrators and clinicians can demonstrate the value o f their efforts by achieving measurable improvements in the health and well-being o f children in the communities they serve. To improve the health and well-being of children with asthma, health policy makers and clinicians must understand both the context within which asthma health services occur and the relative contribution of patient-related factors and contextual factors to health services use. Therefore, this research used the Behavior Model o f Utilization to explore the relative contribution of patient-related factors and contextual factors to pediatric asthma health services utilization behaviors. The conceptual framework offered a systematic and organized approach to identify and test various factors that influence pediatric asthma health services. More importantly, the conceptual model ensured all available factors were equally considered. A non-experimentaL, observational, longitudinal historical research design with three independent groups was used to test the explanatory power o f the Behavior Model o f Utilization. This study was unique in that one o f the comparison groups included participants who declined to enroll in the asthma management program despite referral by Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. their primary care providers. Data sets were linked to create an individual sample of children with diem primary care providers. Explanatory models, based on logistic regression analyses, were developed at the participant and primary care provider level. Previously unexplored variables, such as primary care provider gender and the availability of neighborhood-based primary care provider services, were included in the model, hi this study, the child was the unit of analysis instead of the health services resource claim. Study results revealed that the asthma management program, a contextual factor, significantly reduced the likelihood o f using health services and controlled cost for this insured pediatric population. Participants enrolled in the asthma management program were significantly less likely to be admitted to the hospital, use emergency department services, or use specialist services. Participants were also significantly less likely to be classified high total health care cost These results were further supported when pre-test year results were compared to post-test year results. Finally, these participants were significantly less likely to use beta-agomst medications than participants not enrolled in the program. Study results also revealed that the asthma management program was the only significant predictor variable across all health services outcome measures, when holding the pre-test year measures constant The asthma management program contributed more to the explanatory power o f the Behavior Model o f Utilization than population-related factors or environment-related factors. Additionally, the program contributed as much or more to the explanatory power o f the model than pre-test year measures. Finally, the asthma management program enabled the managed care company to meet health policy objectives and positions the company to receive a favorable review for the asthma quality indicator defined by the National Committee for Quality Assurance. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. DEDICATION Across American, in urban areas and small towns, people are working hard to improve the health and well-being o f children in their communities. As a result, many wonderful things are being achieved However, many are struggling to demonstrate the value o f their efforts. Community leaders want results. Public and private funders, underwriting the work, also want results. (Health Forum, American Hospital Association, 1999). Administrators and clinicians, in managed care organizations, are working hard to achieve and demonstrate measurable improvements in the health and well-being o f children in the communities they serve. This dissertation is dedicated to these stewards o f community health and well-being my colleagues. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. iii ACKNOWLEDGMENTS Many sacrifices were made by my fam ily during the completion o f this work. I would like to acknowledge and thank my husband, Donnie, fo r his unconditional love and support. To my sons, Micfuiel and Chris, thanks fo r the words o f encouragement. To my parents, Billy and Marie, thanks fo r teaching me that life ’s journey has many roads from which to choose and giving me the wisdom to make the best choice. To the rest o f my fam ily and friends, thanks fo r being there. A special thank you to Dr. Randy Axelrod, my mentor andfriend, whose vision provides the premise fo r this work. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS Chapter Page L INTRODUCTION. 1 RESEARCH OVERVIEW. 1 BEHAVIOR MODEL OF UTILIZATION FOR PEDIATRIC HEALTH SERVICES USE. 2 BEHAVIOR MODEL OF UTILIZATION EMPIRICAL STUDY. 3 BEHAVIOR MODEL OF UTILIZATION FOR PEDIATRIC ASTHMA HEALTH SERVICES. 4 BACKGROUND. 5 STATEMENT OF THE PROBLEM. 12 PURPOSE OF THE STUDY.14 OVERVIEW OF CONCEPTUAL FRAMEWORK.15 RESEARCH QUESTIONS. 16 SIGNIFICANCE OF THE STUDY. 17 LIMITATIONS OF THE STUDY. 19 n. LITERATURE REVIEW. 22 INTRODUCTION. 22 CONCEPTUAL FRAMEWORK. 22 BEHAVIOR MODEL OF UTILIZATION.24 BEHAVIOR MODEL OF UTILIZATION FOR PEDIATRIC ASTHMA IN MANAGED CARE COMPANIES. 24 LIMITATIONS OF PREVIOUS RESEARCH. 58 IIL METHODS. 63 INTRODUCTION. 63 RESEARCH DESIGN. 63 DATA COLLECTION AND SOURCES OR DATA.64 STUDY VARIABLES. 65 HUMAN SUBJECTS. 74 RESEARCH PROCEDURES. 75 HEALTH CARE SETTING AND STUDY POPULATION 76 STUDY SAMPLE SELECTION. 78 STUDY POPULATION DESCRIPTION FOR POST-TEST YEAR. 83 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS Chapter HL METHODS. COMPARABILITY OF STUDY GROUPS PRE-TEST YEAR. 88 RESEARCH HYPOTHESES. 97 STATISTICAL TESTS. 125 IV. RESULTS. 133 INTRODUCTION.133 DEPENDENT VARIABLE: HEALTH SERVICES USE/COST. 133 RESEARCH HYPOTHESES: BIVARIATE RELATIONSHIPS. 136 BIVARIATE RELATIONSHIPS BETWEEN POPULATIONRELATED FACTORS AND THE DEPENDENT VARIABLE. 142 BIVARIATE RELATIONSHIPS BETWEEN ENVIRONMENTRELATED FACTORS AND THE DEPENDENT VARIABLE. 154 RESEARCH HYPOTHESES: MULTIVARIATE RELATIONSHIPS.173 V. CONCLUSIONS, IMPLICATIONS FOR HEALTH POLICY, AND RECOMMENDATIONS FOR FURTHER RESEARCH. 217 INTRODUCTION. 217 ASTHMA MANAGEMENT PROGRAM. 218 IMPLICATIONS FOR ASTHMA-RELATED HEALTH POLICY. 240 BEHAVIOR MODEL OF UTILIZATION IN PEDIATRIC ASTHMA HEALTH CARE. 244 RECOMMENDATIONS FOR FURTHER RESEARCH. 245 REFERENCES. 248 APPENDICES. 256 APPENDIX A: SUMMARY RESULTS FOR BIVARIATE ANALYSES.