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UNMET NEED FOR MEDICAL CARE — ROSENFELD ET AL.
tive.11- 13 Although the patient described aboye suffered a long chain of severe postoperative complications and eventually succumbed to generalized septicemia and septic shock, the perforating aneurysm itself was successfully managed.
2.
3.
4.
369
Hunt, H. H., and Welter, C. V. Syndrome of abdominal aortic aneurysm rupturing into gastrointestinal tract: summary of literature and case report. Am. Heart J. 32:571-578, 1946. Bagnuolo, W. G., and Bennett, H. D. Nontraumatic aortic perforations into gastrointestinal tract. review of literature and report of unusual case. Am. Heart J. 40:784-788, 1950. Coggeshall, W. E., and Genovese, P. D. Rupture of abdominal aneurysm associated with massive gastrointestinal hemorrhage. Am.
Heart J. 40:789-792, 1950. 5.
SUMMARY
Hirst, A. E., Jr., and Affeldt, J. E. Abdominal aortic aneurysm with rupture into duodenum: report of eight cases. Castro-
enterology 17:504-514, 1951.
An unusual case of an iliac-artery aneurysm that perforated into the sigmoid colon was treated surgically. The diagnostic and therapeutic implications are discussed, and a plea is made for early diagnosis and prompt surgical therapy. I am indebted to Drs. David E. Davidoff and Edward D. Frank, of the Department of Surgery, Dr. Feliz G. Fleischner, chief of the Department of Radiology, and Dr. David G. Freiman, chief of the Department of Pathology, Beth Israel Hospital, for their assistance in the preparation of this paper.
6.
Kane, J. M., Meyer, K. A., and Kozoll, D. D. Anatomical approach to problem of massive gastrointestinal hemorrhage. Arch.
Surg. 70:570.582, 1955. 7.
Brick, 1. B., and Jeghers, H. J. Gastrointestinal hemorrhage (excluding peptic ulcer and esophageal varices). Neto Eng. J. Med.
253:458-466, 1955.
8.
9.
10.
II.
Ross, C. F., and Pheils, M. T. Fatal gastrointestinal hemorrhage due to perforation of ileum by atheromatous aneurysm of abdominal aorta. Gastroenterology 32:756758, 1957. Abramson, P. D., and Jameson, J. B. Rupture of iliac aneurysm luto duodenum: unusual cause of upper gastrointestinal hemorrhage. Arch. Surg. 71:658-661, 1955. Jackman, R. J., McQuarrie, H. B., and Edwards, J. E. Fatal rectal hemorrhage caused by aneurysm of internal Bine artery: report of case. Proc. Staff Meet., Mayo Clin. 23:305-308, 1948. Crane, C. Arteriosclerotic aneurysm of abdominal aorta: some pathological and clinical correlations. Neto Eng. J. Med. 253:954-
958, 1955. REFERENCES
I.
Rottino, A. Aneurysm of abdominal aorta, with rupture into duodenum: case report and review of literature. Am. Heart J.
12.
Maniglia, R., and Gregory, J. E. Increasing incidente of arteriosclerotic aortic aneurysms: analysis of six thousand autopsies. Arch.
13.
Wright, I. S., Urdaneta, E., and Wright, B. Re-opening case of abdominal aortic aneurysm. Circulation 13:754-768, 1956.
Path. 54:298-305, 1952.
25:826-836, 1943.
SPECIAL ARTICLE UNMET NEED FOR MEDICAL CARE* LEONARD
S.
ROSENFELD,
AVEDIS DONABEDIAN, M.D.,t AND JACOS KATZ,
M.A.§
BOSTON
TNCREASING amounts of money and effort are being expended on the organization and provision of medical services, as well as on research and professional education. Practicing physicians, hospital, medical-care and public-health administrators, as well as many other groups, are deeply absorbed in the dayto-day task of meeting medical-care needs. Nevertheless, there are few yardsticks for measuring how effective these efforts are in terms of the potentialities of medicine. The possible value of such yardsticks in maintaining and improving standards of service seem self-evident. This report is based on a series of three studies designed to measure the distribution of unmet need for medical care in the community. These studies form part of a research program undertaken to devise methods for evaluating the effectiveness of a proposed •From Medical Care Evaluation Studies, Health Division, United Community Services of Metropolitan Boston. Supported in part by a research grant (R. G. 4045) from the National Institutes of Health, United States Public Health Service. +Assistant executive director, Community Health Association, Detroit. Michigan; formerly, instructor in medical care. Harvard School of Pubc Health, and director, Medical Care Evaluation Studies, United Community Services of Metropolitan Boston. s.:Assistant professor of preventivc medicine, New York Medical College. New York City; formerly, research associate in medical care, Harvard School of Public Health, and medical associate, Medical Care Evaluation Studies, United Community Services of Metropolitan Boston. §Instructor, Department of Sociology, Boston University; formerly, research associate, Medical Care Evaluation Studies, United Community Services of Metropolitan Boston.
program of regional organization of health services. Reports on studies of quality of medical carel and efficiency of utilization of facilities.' have been published separately. APPROACH
For purposes of this study the availability of medical care has been defined as the ease and readiness with which service is obtained in response to need. In its efforts to improve availability of health services, a comprehensive program of community organization not only should be involved in the supply and distribution of services but should also be concerned with removing barriers — financial, cultural or geographic — to their effective utilization. It follows from these premises that the extent to which needs for medical care are satisfied is one of the ultimate criteria for successful organization. Need for medical care may be expressed as the aggregate of services required by individuals or population groups to promote health and avert or postpone disability and death. It includes all professional services directed at prevention, early diagnosis, treatment and rehabilitation in accordance with the dictates of good medical practice. Unmet need is the difference between the amount of medical care ac-
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THE NEW ENGLAND JOURNAL OF MEDICINE
tually received and the amount that might be recommended under ideal conditions. Accurate measurement of the magnitude and distribution of need for medical care in any population group is a complex and difficult task. To be complete, such estimates not only should be based on information reported by the individual but also should take into account data that might be revealed upon thorough clinical examination. Translation of findings on mortality, morbidity or clisability (whether obtained through interview surveys or by clinical investigation) into equivalents in terms of services needed for optimum medical care is a further obstacle not easily overcome. More than two decades ago, Lee and Jones3 attempted to develop service equivalents for a wide variety of diagnoses. These estimates are based on largely hypothetical premises, and take no account of the coexistence of multiple diseases, stage and severity of illness, age, sex, employment status or the many social and economic factors that modify needs for medical care. Moreover, medical progress has by now probably rendered many of the Lee—Jones estimates obsolete. In recent surveys conducted in Hunterdon County" and Baltimore6 an attempt was made to examine selected samples of population and arrive at estimates of need for medical care based on clinical and laboratory findings in each case. This method (although perhaps the best available for obtaining realistic estimates of need) is extremely expensive, calls for an unusual degree of co-operation on the part of the surveyed population and tends to emphasize chronic illness and disability at the expense of illness of shorter duration but possibly higher incidence. Some years ago Hoffer and his co-workers7 pioneered an ingenious approach to the exploration of medical need. By means of a household survey they determined the proportion of individuals who had experienced (during a specified period) one or more of a list of symptoms that, in the opinion of physicians, require medical attention. The occurrence of one or more symptoms was taken to denote need, and the nonreceipt of professional attention for these symptoms as an indication of unmet need for medical care. Rather than measure the total extent of need, the symptom survey concerns itself with a limited segment from which it may be possible to draw conclusions concerning the extent and distribution of unmet need for medical care generally. Owing to the many difficulties inherent in making complete estimates of need and unmet need for entire population groups, the current studies were initiated as an attempt to explore the use of fairly simple indexes that might reflect the degree of unmet need in more restricted fields of medical care. This approach rests on the hypothesis that, on the whole, a community defective in one area of medical care is probably below par in other areas as well. If this is true, it
Feb. 20, 1958
should be possible, by means of a number of properly selected indexes, to obtain a valid picture of the effectiveness of health services in the community as a whole. Stated more precisely, the objectives of these studies were as follows: to construct suitable indexes of unmet need for medical care; to develop a uniform method for plotting the distribution of unmet need within a community; to demonstrate the existence of correspondence or correlation between indexes; and to indicate the usefulness and limitations of such indexes in program planning and evaluation. INDEXES OF UNMET NEED*
It was postulated at the outset that, to be useful, the indexes chosen should be valid, based on specific objective data, feasible in terms of cost and applicable to many communities. The following are the indexes studied and the hypotheses that are relevant to each: Perinatal Mortality
It is recognized that an appreciable proportion of stillbirths and neonatal deaths can be prevented by adequate prenatal care, competent management of delivery and subsequent care of the newborn infant. The perinatal mortality, although influenced by various biologic, social and economic factors," should (in large part) reflect the adequacy of medical supervision available during pregnancy and childbirth. Inadequacy of Prenatal Care
Experience in obstetrics has resulted in the development of minimum standards of adequate prenatal care necessary to reduce the risk of pregnancy and childbirth.13,13 Where adequate medical care is available, levels of prenatal care should approach recommended standards. Two indexes based on prenatal care have been constructed. The first, which indicates the quantitative adequacy of prenatal supervision, is expressed as the proportion of mothers with "unsatisfactory" amounts of prenatal care. The second is based on the assumption that at least one visit to a dentist should be made during pregnancy, and is expressed as the proportion of mothers who have not visited a dentist. Neglect of Important Symptoms
This index is constructed by determination of the number of persons in the general population who have experienced, during the period of six months, one or more of a list of symptoms considered impor*The individual indexes, the methods used in constructing them and the extent to which they satisfy the several postulated criteria are only briefly described in this paper. More detailed information may be obtained from separate reports on each oĂ these studies.8-,0
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UNMET NEED FOR MEDICAL CARE—ROSENFELD ET AL.
tant enough to merit medical care. The proportion of persons who have not obtained medical care for one or more of these symptoms has been used as an index oĂ unmet need. Neglect of Dental Care
1t is assumed that each person between five and sixty-four years of age should make at least one visit to a dentist every six months. The proportion of persons within this age range who have not made at least one such visit has been proposed as an index of unmet need.
It should be noted that the index of perinatal mortality constitutes an assessment of the end result of a multitude of factors, which include the quantity and quality of obstetric and pediatric care. The remaining four indexes differ from the first in that they postulate explicit minimum standards, relate merely to the quantity of care without regard to quality and are assessments of intermediate goals rather than more remote end results.* In addition to the indexes listed aboye, consideration was given to several others that, for various reasons, it was not possible to adopt. A brief account of these is given below : An attempt to use the proportion of first-grade children shown by the school vision-testing program to have uncorrected defects as one index of unmet need was abandoned when it became apparent that, for this age group, the results of the standard vision test were not sufficiently reliable." Another study designed to develop an index based on the prevalence of hearing defects in school children was canceled owing to a shortage of personnel at the Division of School Hygiene. Selective Service data are another source of information about the health status of a large segment of the population. Problems of obtaining a representative sample, and the fact that many physical defects in this age group reflect deficiencies in medical care in early childhood, suggested that these data could not be readily used for development of indexes of the current status of medical care. Plans for a study of the extent of delay in seeking treatment for cancers of selected sites were suspended when it became known that the National Cancer Institute had recently completed a study designed to determine the delay in treatment of cancer of selected sites (as indicated by the localization or extension of the disease) as related to socioeconomic status. Since methods very similar to those planned in this study were used, the study was abandoned." Unmet Need and Socioeconomic Status
Indexes that merely indicate the level of unmet *A discussion of intermediate goals and end results in evaluation of health services is presented by Sheps" and Knutson and Shimberg."
371
need for the community as a whole are of limited practical value. Their usefulness, whether employed as tools for evaluation or merely for descriptive purposes, would be greatly enhanced by plotting of the distribution of unmet need within the community. There is much evidence that both need and unmet need for medical care are more prevalent among the socially less fortunate segments of the community. On the basis of the hypothesis that socioeconomic status is a principal determinant of unmet need for medical care. the several studies were designed to determine relations between indexes of unmet need and socioeconomic status. In these studies three variables (income, education and occupation) were used, singly or in combination, as criteria for determining socioeconomic status. These factors were chosen because they are widely reported, are easy to express in quantitative terms, and have been shown by numerous investigations to be intimately related to both need and unmet need for medical care. There is some evidence that these variables are associated with other important socioeconomic factors, such as understanding of health needs, attitudes toward medical care, value systems and other cultural characteristics that are related to the recognition of need for medical care and subsequent action to meet this need. Further research into the degree of relation between these factors and unmet need might produce other, or better, axes for classification of population groups in studies of unmet need for medical care. Ordinarily, information concerning social and economic characteristics of families is not available with many forms of health data although the subject's address is of ten provided. Since the purpose of these studies was to develop methods that could be applied uniformly to a wide variety of health indexes, families were also classified according to the average characteristics of the census tract in which they lived.t One aim of the study was to test the validity of a socioeconomic classification of individuals and families based on census-tract characteristics by comparison of results obtained by means of this method with those obtained by the use of socioeconomic information gathered from individual families during the course of the study. METHOD
The Study Area
Since the primary purpose of these studies was to develop a method, rather than to conduct a survey, a segment of Metropolitan Boston comprising 90 contiguous census tracts was chosen as the study area. This area has a population of approximately 500,000 ÂĄCensus tracts are small geographic units into which metropolitan amas are subdivided. They are delineated in a manner generally to include populations of between 3000 and 6000 that are more or less homogeneous sonally and economically. Fairly detailed information about various characteristics (such as income, education and occupation) of censustract populations are published at each decennial census. The tract of residence is easily identified if the address of the subject is known.
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and representa a wide range of social and economic characteristics among its component census tracts. It is, in addition, fairly representative of the Boston standard metropolitan area in several demographic and socioeconomic variables. Data
Source of
For constructing the index of perinatal mortality, data on live births, stillbirths and neonatal deaths TABLE 1.
FINDINGS
The data were analyzed primarily with a view to demonstrating the relation between each index and socioeconomic status as determined by census tract of residente. When possible the data were also related to individual and family characteristics such as income, education and occupation to demonstrate similarities or differences between the results obtained by this method and those obtained by the use of average
Indexes of Unmet Need for Medical Care, According to Socioeconomic Status of Census Tracts of Residence.
Socacummoterc STATUS OP GROUP
PERINATAL MORTALITY .
HOUSEHOLD SURVEY:
PRENATAL CABE
"
PERGENTAGE UNSATISPAGTORY"
PERCENTAGE WITH NO DENTAL VISITS
PERCENTACE WITH ONE OR MORE UNTREATED SYMPTOMS
PERGENTAGE WITH NO DENTAL VISITS DURING 6 nro.§
All groups
35.0
35.0
57.9
43.3
59.2
I (lowest)
46.0
68.4
84.6
50.0
73.9
II
37.2
46.7
74.4
43.5
71.7
III
33.1
24.9
45.6
44.3
56.7
IV
29.4
19.4f
39.9t
38.5
44.4
V (highest)
24.7
29.7
41.0
*Stillbirths + neonatal deaths live births + stillbirths tGroups IV & V combined.
X 1000
*Percentage for each socioeconomic group standardized for age & ses. §Persons between ages of 5 & 64 yr.
during a five-year period (1950-1954) were obtained from the usual official sources. To obtain information on prenatal care a self-administered questionnaire was distributed, on the third post-partum day, to all mothers who were delivered during the period of a month in 21 hospitals serving the study area. Information about neglected symptoms was obtained through a household survey of a representative sample drawn from the study area. The sample included 1070 households with 3387 individuals. Basically, the survey schedule consisted of a list of 31 symptoms and was similar to that developed by Hoffer and his co-workers' in Michigan. The respondent was asked to report (for each member of the household) which of these symptoms had been experienced during the previous six months, and which had received medical attention, and from what source. The schedule included questions on the receipt of dental care during the previous six months. Scores of Socioeconomic Status
Census tracts were assigned scores of socioeconomic status with a modification of the method described by Shevky and Be11. 18 A combined score based on income, education and occupation was used to classify census tracts into five socioeconomic groups. Group I is the lowest, and Group V the highest, in rank. In some cases, owing to small numbers, the highest two groups were combined.* *Detailed description of the study area and method used to classify census traces into socioeconomic groups is given in other reporta in this
series.*'°
census-tract characteristics as determinants of socioeconomic status. An attempt was also made (by means of a uniform scale) to consider the four indexes together, and to show the magnitude of relative differences between socioeconomic groups as revealed by each index. Perinatal mortality in the 90 census tracts of the study area ranged from 13.9 to 73.4 per 1000 births (stillborn and live births), with an average of 35.0 and a median of 34.6. By grouping of census tracts into five equal intervals of combined score, a consistent decline in mortality was found with improvement in socioeconomic status (Table 1) . Mortality in the lowest socioeconomic group is almost twice as high as that in the highest socioeconomic group. This relation is statistically significant (P< 0.001) . 8 Similarly, data on prenatal care (Table 1) show a distinct relation between the adequacy of care and socioeconomic status. The quantity of care received was rated "unsatisfactory" in 68 per cent of respondents in the lowest socioeconomic group, whereas only 19 per cent in the highest two groups received unsatisfactory care. No dental visits were made during the current pregnancy by 85 per cent of respondents in the lowest socioeconomic group, and 40 per cent of those in the highest two groups. It is apparent that the differences between groups are marked, and that there is much room for improvement in all groups, especially in the receipt of dental care. The prenatal-care survey provided an opportunity for obtaining information about family income, edu-
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UNMET NEED FOR MEDICAL CARE — ROSENFELD ET AL.
cation of the respondent and occupation of the spouse. When quantitative adequacy and the receipt of dental care were related to these socioeconomic data, the picture obtained differed little from that obtained by the use of census tract of residence to determine socioeconomic status.° The results of the household survey are in general ag,reement with those already presented (Table 1). Of persons who had one or more symptoms believed to require medical attention, only 43 per cent had received medical care. In the lowest socioeconomic group, 50 per cent of persons with symptoms had one or more untreated symptoms. In the highest socioeconomic group, the proportion with one or more untreated symptoms was 30 per cent. During a sixmonth period, taking into account only persons between five and sixty-four years of age, a dentist was not visited by 41 per cent of persons in the highest socioeconomic group and 74 per cent of those in the lowest group. When the proportion of persons with untreated symptoms and the proportion who had not made dental visits were determined according to family income or education of the head of the household, the results were substantially similar to those shown above.'° To compare the five indexes for level of unmet need and the magnitude of relative differences between socioeconomic groups as revealed by each index, it was necessary to express them all in terms of a uniform scale. The ratio of unrnet to met need in each socioeconomic group appeared to be the most suitable unit for this purpose.* Figure 1 and Table 2 show the ratio of unmet to met need for each of the five indexes. It is very clear that the likelihood of perinatal death is very small as compared with that of perinatal survival. For the other indexes, the likelihood of unmet need is much greater, and, in certain cases, there are considerably more persons with unmet than with met need. In Figure 2 the value of the ratio of unmet to met need in the highest socioeconomic group is arbitrarily fixed as 1, and the values for the other groups are expressed as multiples of 1. The slopes of the various graphs indicate the magnitude of relative differences between groups. Perinatal mortality and the percentage of persons with one or more untreated symptoms run roughly parallel and show the least differences between groups. The two prenatal-care indexes show the largest differences between groups, whereas the "This unit mas adopted because it reveals the same magnitude of differences between socioeconomic groups, irrespective of whether the index is expressed in terms of met need or unmet need. To portray faithfully the proportionate differences between socioeconomic grottps, the logarithm of this ratio was used for graphic presentation (Fig. 1). The logarithm of the ratio of muna need to met need has an additional advantage in that it may. theoretieally, range from minus infinity to plus infinity, and offets a scale that is free of restrictions at either end. An example of constructing this ratio follows. In socioeconomic Group I the risk of perinatal death is 0.046. The likelihood of survival is therefore 0.954. The ratio of unmet need to met need is 0.0464-0.954=0.048 (log=2.683).
373
index based on the receipt of dental care by the general population occupies an intermediate position. For all indexes the likelihood of unmet need is substantially higher in the lowest socioeconomic group than it is in the highest — that is, twofold for perinatal mortality and untreated symptoms, fourfold for failure to visit a dentist during a period of six months AMOUNT OF PRENATAL GARE -•-•-•- PRENATAL DENTAL VISITS DENTAL VISITS DURING 6 MONTNS 50 -
••••
• ..
-•--•-- PERNATAL mORTALITV
'2 4 O -
›
ONE OR MORE UNTREATED SVMPTOMS
to
▪ 0.8 •
0.6
2 I
0.4 -
O
–
2 008 -
002 -
o 0-OÑIEST) SOGIOEGONOMIG GROUP
Y
ANIGNEST)
Ratio of Unmet Need to Met Need for Five Indexes of Unmet Need for Medical Care, According to Socioeconomic Status and Census Tract of Residence.
FIGURE 1.
and eightfold to ninefold for the occurrence of unsatisfactory prenatal care Cor nonreceipt of dental care during pregnancy. DISCUSSION
A major objective of these studies was to develop valid, reliable and objective (though relatively simple and inexpensive) methods that might be employed at fairly close intervals to evaluate programs and measure progress. It is necessary to consider to what extent these criteria have been met by the indexes proposed. The vital data on which the perinatal-mortality index is based are specific, generally reliable and relatively easy to obtain. Although it is fully realized that perinatal mortality represents the end result of many factors, some of which are related to medical care and some of which are not, the available evidence suggests that the medical-care component is sufficiently large to justify the use of perinatal mortality as an index of unmet need for medica] care.8 Judging by various reports in the literature,18-" it does not appear unreasonable to expect a 30 to 40 per cent reduction in perinatal mortality through the application of medical knowledge already at hand.
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THE NEW ENGLAND JOURNAL OF MEDICINE
374
Experience with the prenatal survey has shown that the basic information is valid, reliable and relatively easy to obtain. 9 In effect, the data are actual determinations of the amount of care received that, by reference to generally accepted standards of antenatal supervision, should provide a direct measurement of unmet need for medical care.
found whether the family was classified according to characteristics of the census tract or of the family. Although it is known that the population of any given census tract is not entirely homogeneous in socioeconomic characteristics, 25 the heterogeneity that does exist is not sufficient to distort the picture of socioeconomic distribution of unmet need for medical care
TABLE 2. Ratio of Unmet Need to Met Need for Five Indexes of Unmet Need for Medical Care, According to Socioeconomic Status of Census Tracts of Residence.
RATIO OF
SOCIOECONODEIC GROUP PERINATAL MORTALITY
AMOUNT Or PRENATAL CABE
UNMET NEED TO MET NEED
PRENATAL DENTAL VISITE
tYMBP-ATEB SYMPTOMS
CĂ&#x2030;NTAL VISITE
AH Groups
0.036
0.537
1.372
0.764
1.449
I (lowest)
0.048
2,167
5.502
1.001
2.833 2.529
II
0.039
0,875
2.899
0.770
III
0.034
0.331
0.838
0.797
1.309
IV
0.030
0.625
0.799
V (highest)
0.025
0.422
0.696
0.241*
0.663*
*Groups IV & V combined.
The household survey represents a much larger investment of time and money than was required for constructing the other indexes of unmet need. Nevertheless, the cost is not prohibitive, and the range of information that can be collected might recommend this method to at least some communities. Recently, the validity of morbidity data obtained through household surveys has been subjected to critical appraisa1. 22,23 Nevertheless, in spite of its manif est limitations, the symptom survey should remain a valuable tool for exploring unmet need, for the following reasons : it is his own recognition of symptoms that generally motivates a person to seek medical care; certain symptoms are of ten associated with serious illness that deserves medical attention; disabling symptoms require attention, even though they may not be accompanied by physical or physiologic changes detectable by usual diagnostic procedures; and although the patient may not be able to report illnesses by diagnosis, he should be able to describe symptoms he has experienced. In addition to these a priori arguments, there is some experimental evidente to support the validity of the symptom survey. 7,24* It may be concluded that, although the full significante of data collected by means of the symptom survey is not clear, it provides a practical method of measurement based on an operational definition, which would meet the requirements of this study. Unmet Need and Socioeconomic Status
Similar discrimination between socioeconomic groups regarding the adequacy of prenatal care and unmet need as measured by the symptom survey was *A further discussion of the validity and limitations of the symptom survey is given elsewhere."
as measured in these studies. It seems likely that the effects of within-tract heterogeneity are counteracted, to a degree, by shared patterns of behavior and attitudes toward medical care among families living in the same neighborhood. Use of census-tract data for characterizing residents permits comparative analysis of a variety of morbidity, mortality and other statistics that can be related to census tracts but for which socioeconomic information on an individual basis is not available It also allows geographic delineation of areas of relatively high and low unmet need. 26 The results of these studies demonstrate clearly that the five indexes adopted have the same kind of relation to socioeconomic status, although they differ in degree. These findings support the hypothesis that unmet need in one area of medical care is of ten associated with deficiencies in other fields as well. If this is true, it should be reasonable to expect a number of well chosen indexes to provide a useful profile of the magnitude and distribution of unmet need within a community. P ractica r Applications
There appear to be several practical applications for indexes of unmet need such as the ones proposed. They should be useful in conducting a general community survey to estimate the effectiveness of existing facilities and services. It should also be possible, with the same methods in different communities, to make valid comparisons between them. It is suggested that the same methods, used periodically in the same community, will provide a means of determining change in the level and distribution of unmet need. If the indexes are applied before the initiation of a compre-
• Vol. 258 No. 8
UNMET NEED FOR MEDICAL CARE—ROSENFELD ET AL.
hensive program of organization of health services, and also at successive intervals thereaf ter, changes in the level and distribution of unmet need may be taken as a presumptive measure of the effectiveness of such a program. This interpretation must remain hypothetical until there is further evidence of the causeand-effect relations between medica] care and indexes based on perinatal mortality and symptoms. In interpreting the "profile" of unmet need as revealed by these indexes, one should pay attention to two attributes of each index — the level and the slope. Within certain limits, the level of the index indicates the magnitude of deficiency in medical care; the slope denotes differences between groups. It is believed that comparison between segments of the population within the same community is especially valuable, since the group with the most favorable experience may be used as a standard against which all others may be measured. Improvements in the provision and effective use of medical services should become evident in one or both of two ways. The general level of unmet need should be reduced, and the differences between groups should become less marked. There is reason
AMOUNT OF PRENATAL CARE -
8,0 -
•
7.0 -
PRENATAL DENTAL VI SITS
DENTAL VISITS DURNG 6 MONTHS - ONE OR MORE UNTREATED SYMPTOMS PERINATAL
e z
6.0 -
MORTALITY
1.-
MUL TI PLE S OFRATIOOFUNM E T
; 5.0 -
4.0 -
2.0 -
375
comprehensive program of community organization and, by the same token, an important criterion of success in making care available to all segments of the population. Although differences in standards of living among various groups in the community will persist, the general trend in public policy is to make adequate medical care available to all groups. This is the function of public medical care, community planning of facilities, public subsidy for construction of facilities and organization of prepaid services. The degree to which availability of medical care is separated from income and other socioeconomic attributes may be accepted as a decisive test of the success of community organization of health services. Although indexes of unmet need appear to possess intriguing possibilities, they also have certain limitations that should be kept in mind. I t is recognized that the indexes, whether considered singly or together, will only indicate the extent of need and plot its distribution. They will not provide any explanation of underlying factors. Unmet need may result from any one of several circumstances. The community might not provide services of good quality. On the other hand, services might be provided but not utilized. Obstacles to utilization might be geographic, cultural or financial. The index points to a deficiency, but only further investigation will reveal the causes of defective utilization. Programs specifically directed at improving the area of need reflected by any one index will curtail its usefulness as an indicator of the general picture of medical care. Hence, there is need for several indexes drawn from as wide an area of medical care as possible. Still another limitation to consider is the extent to which factors extraneous to the availability of medical care might influence some of the indexes, such as the one based on perinatal mortality. Caution must therefore be exercised in the use of the indexes as instruments for evaluating the effectiveness of any specific program of health-service organization. In an attempt to estimate the extent to which health programs are responsible for observed changes in the prevalence and distribution of unmet need, the contribution of concurrent secular changes (including social and economic amelioration as well as the effects of medical progress) must also be taken into account.
oT Need for Further Study
Y CHIGHEST) SOCIOECONOMIG GROUP
CLOWEST)
FIGURE 2. Ratio of Unmet Need to Met Need in Each of Five Socioeconomic Groups, Expressed as a Multiple of the Ratio in the Highest Socioeconomic Group.
to believe that, in the natural course of events, the differences in need and unmet need between high and low socioeconomic groups tend to persist in spite of improvements in social and economic conditions and the progress of medical science.27,28 The reduction of such disparities may be one legitimate objective of a
'l'he current studies are recognized to be a very modest and rather tentative exploration of a field in which there is need for much further research. There appears to be an urgent need for simple, valid tools for evaluating the effectiveness of health programs. These findings are presented with the hope that they will stimulate interest, and perhaps lead to further effort in this direction. More detailed studies would be needed to establish beyond doubt the validity of some of the indexes pro-
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posed. One such study might attempt to identify the various factors responsible for perinatal mortality with a view to assessing the importante of medical care in preventing perinatal death. Not much is known about the many factors that interfere with effective utilization of health services provided by the community. More studies of attitudes, motivation, recognition of need and problems in obtaining needed service would be useful in identifying and measuring the relative force of the several factors at work. There is need for administrative studies aimed at clarifying the relation between organizational aspects of programs and their success or failure in satisfying needs for medical care. The proposed indexes might facilitate research in this general field by identifying groups with high and low levels of unmet need. Further intensiva epidemiologic and clinical studies in groups at the two extremes might prove fruitful in shedding light on the nature, extent and causation of both need and unmet need in the general arca of health and medical care. We are indebted to the Committee on Medical Care Evaluation Studies of the United Community Services of Metropolitan Boston, Dr. Hugo Muench, chairman, and to Dr. Robert B. Reed, statistical consultant, for help in this study.
7.
Hoffer, C. R., et al. Health Needs and Health Care in Michigan. (Special Bulletin 365.) 94 pp. East Lansing, Michigan: Michigan State College, June, 1950. 8. Rosenfeld, L. S., and Donabedian, A. Studies in Unmet Need for Medical Care. I. Perinatal Mortality. 22 pp. Boston: Medical Care Evaluation Studies, United Community Services, 1957. 9. Idem. Studies in Unmet Need for Medical Care. II. Prenatal Care. 20 pp. Boston: Medical Care Evaluation Studies, United Community Services, 1957. 10. Rosenfeld, L. S., Katz, J., and Donabedian, A. Medical Care Needs and Services in Boston. 147 pp. Boston: Medical Care Evaluation Studies, United Community Services, 1957. 11. United Nations. Foetal, Infant and Early Childhood Mortality. vols. Vol. 1. The Statistics. Vol. 2. Biological, Social and Economic Factor:. Vol. 2. (Population studies, Number 13.) New York: Columbia, 1954. 12. United States Department of Labor, Children's Bureau. Standards al Prenatal Care: An outline for the use of physicians. Second edition. 5 pp. (Bureau Publication No. 153.) Washington, D. C.: Government Printing Office, 1940. 13. Massachusetts Medical Society: Committee on Maternal Welfare: (John F. Jewett, M.D., Chairman): minimum standards of obstetrir care. New Eng. J. Med. 252:739, 1955. 14. Sheps, M. D. Assessing effectiveness of programs in operation. In Administrativo Medicine: Transactions of the fourth conference, October 31, November 1-7, 1955, Princeton, New Jersey. Edited by
G. S. Stevenson. 251 pp. New York: Josiah Macy, Jr., Foundation, 1956. Pp. 111-124. Knutson, A. L., and Shimberg, B. Evaluation of health education program. Am. J. Pub. Health 45:21-27, 1955. 16. Donabedian, A., and Rosenfeld, L. S. Replicabiity of standarffized screening test for visual acuity among school children. Sight-Saving Reo. (in presa). 17. Haenszel, W. Personal communication. 18. Shevky, E., and Bell, W. Social Area Analysis: Theory, illustrative application and computational procedures. 70 pp. Stanford, California: Standard University Press, 1955. 19. Kohl, S. G. Perinatal Mortality in New York City: Responsible fac15.
tor,: Study of 955 deaths by Subcommittee on Neonatal Mortality, Committee on Public Health Relations, New York Academy of Medicine. 112 pp. Boston: Harvard University Press for Common-
wealth Fund, 1955. Bundesen, H. N. Effective reduction of needless hebdomadal deaths in hospitals: long-term public health program in Chicago, with special reference to use of alerter system. J.A.M.A. 157:1384-1399, 1955. 21. Steer, C. M., and Kosar, W. P. Causes of fetal mortality at Sloane Hospital for Women, 1940-1949. Am. J. Obst. Gynec. 63:1091110f, 1952. 22. Elinson, J., and Trussell, R. E. Some factors relating to degree of correspondence for diagnostic information as obtained by household interviews and clinical examinations. Am. J. Pub. Health 47:311321, 1957. 23. Kreuger, D. A. Measurement of prevalence of chronic disease by household interviews and clinical evaluations. Presented at the Eighty-fourth Annual Meeting of the American Public Health Association, Atlantic City, New Jersey, November 12-16, 1956. 24. Division of Public Health Methods, Public Health Service, U. S. Department of Health, Education, and Welfare. Health Services for the American Indiana. (Public Health Service Publication No. 531.) 344 pp. Washington, D. C.: Government Printing Office, 1957. Chapter 5. 25. Myers, J. K. Notes on homogeneity of census tracts: methodological 19 problem in urban ecological research. Social Forces 32:364-366, 54. 26. Foley, D. L. Census tracts in urban research. J. Am. Statist. A. 48:733.742, 1953. 27. Morris, J. N., and Heady, H. A. Cited by Douglas." 28. Douglas, J. W. B. Health and survival of infants in different social classes. Lancea 2:440-446, 1951. 20.
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Rosenfeld, L. S. Quality of medical care in hospitals. Am. J. Pub. Health 47:856-865, 1957. Rosenfeld, L. S., Goldmann, F., and Kaprio., L. A. Reason for prolonged hospital stay: study of need for hospital care. J. Chronic Dil. 8:141-151, 1957. Lee, R. I., Jones, L. W., and Jones, B. The Fundamental: of Good Medical Care: An outline of the fundamental: of good medical tare and an estimate of the service required to supply the Medical Needs of the United Mates. (Publications of the Committee on the Costa of
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Medical Care, Number 22.) 302 pp. Chicago: University of Chicago Presa, 1933. Trussell, R. E., and Elinson, J. Measuring needs for medical and related services. In Administrativo Medicine: Transactions of the fourth conjerenco, October 31, November 1-7, 1955, Princeton, New Jersey. Edited by G. S. Stevenson. 251 pp. New York: Josiah Macy,
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Jr., Foundation, 1956. Pp. 9-66. Trassell, R. E., Elinson, J., and Levin, M. L. Comparisons of various metbods of estimating prevalence of chronic disease in community - Hunterdon County study. Am. J. Pub. Health 46:173-
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Commission on Chronic Illness. Census Bureau to aid Commission in Baltimore study of urban chronic illness prevalence and needs. Chronic Illness News Letter 4(3):1, May, 1953. Commonwealth Fund makes $30,000 grant for steps 1 and 2 of Baltimore study. Chronic lUneu News Letter 5(9):1-4, November, 1954. Multiple screening - third step in Baltimore Chronic Illness study. Chronic Bines: News Letter $(7):1-4, September, 1955.
Feb. 20, 1958