Nursing Effectiveness, Utilization and Outcomes Research Unit
McMaster University • University of Toronto
Nursing
EFFECTIVENESS,
UTILIZATION &
OUTCOMES
RESEARCH
UNIT
A collaborative project of
the University of Toronto
Faculty of Nursing and
McMaster University
School of Nursing
Our mission is to
develop, conduct and
disseminate research that
focuses on:
Design
Management
Utilization
Outcomes
Provision
…of nursing
Faculty of Nursing
University of Toronto
50 St. George Street
Toronto, Ontario, Canada
M5S 3H4
Tel: (416) 978-1966
Fax: (416) 978-8222
Faculty of Health
Sciences
School of Nursing
McMaster University
1200 Main Street West
2J40
Hamilton, Ontario,
Canada
L8N 3Z5
Tel:(905)525-9140
x22581
Fax: (905) 522-5493
Funded by the
Ontario Ministry of Health
1996-2004
http://www.fhs.mcmaster.
ca/nru
Fact Sheet:
What Factors Can Influence Health Care Utilization?
There are many factors that can predispose a population to increased or decreased
utilization of health care services. They include: (1) socio-economic status, (2) physician
supply, (3) policies and beliefs of a nation, (4) risk behaviours of a population, and (5)
health status.
How Does SES Have an Effect on Health Care Utilization?
The socio-economic status (SES) of a community is a composite measure based on
factors such as education, income, and demographic characteristics (sex, age, and
ethnicity). It is believed that SES has a significant influence on utilization behaviour
because of its effect on aspects such as need, recognition, and response to symptoms;
knowledge of disease; motivation to get well; and access or choice of health services
(Anderson, 1973; Hulka & Wheat, 1985).
! It is well documented that persons of lower SES experience a greater degree of
disease and mortality. Despite these facts, research has shown that clinic and hospital
use is not reflective of their circumstances -- especially among infants and children.
This disparity in use by young persons of lower SES can result in a disproportionate
amount of use when they are older (Hershey, Luft, & Gianaris, 1975).
! Education and income usually result in higher use of health care, especially
preventive visits and clinic visits; however, educated persons experience less acute
disease (Muller, 1986).
! Research has shown that women have a slightly higher rate of utilization than their
male counterparts (Hulka & Wheat, 1985).
! Age is another significant aspect of SES. Although elderly persons use more health
services, it is not equally distributed among the whole population.
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Research has shown how other factors, such as the presence of
chronic disorders (health status), risk behaviours (e.g., smoking),
and access to care, also play an important role in how and why
the aged use health care. This is an excellent illustration of the
multi-factorial nature of health care utilization and the faults of a
shortsighted approach to health policy decisions (Anderson,
1973; Hershey, Luft, & Gianaris, 1975; Muller 1986).
Can Physician Supply Impact on Health Care Utilization?
Physician supply is not as multifaceted as SES and a large part of the literature illustrates that its
relationships with health care utilization is straight forward. An increase in the proportion of doctors
available or access to doctors in a community consistently results in an increase in health care utilization
of all types. This indicates that many patients will use or be encouraged to use services when the
physician services are made available (Barer, Evans, & Labelle, 1988; Hulka & Wheat, 1985).
How Policy Changes and National Values Can Affect Health Care Utilization
Government policies and the values of a country can have a direct effect on health care utilization. When
a country wants to increase the use of health care by the population it can create policies in order to do so.
The best example of this fact is the introduction of Medicare.
! Twenty years after the introduction of the Medicare system in Canada a number of researchers
(Canadian and international) illustrated that health care systems like Canada's provide more access to
health care for persons of lower SES (Barer, Evans, & Labelle, 1988; Muller, 1986).
Risk Behaviour and Health Care Utilization
Policies, such as the enforcement of wearing seatbelts in vehicles, have also helped to reduce the effects
of risk behaviours that can have a significant impact on health utilization. Unfortunately, government
efforts to reduce other risk behaviours such as smoking and alcohol and drug abuse have not been as
effective. Research has shown that lifetime health costs of smokers are 47% higher despite the lower life
expectancy of smokers (Hodgson, 1992; Rice et al., 1986).
Health Status and Health Care Utilization
Health status is the most important factor associated with increased health care utilization. There is
consistent evidence that shows that lower health status of a population directly results in increased health
care utilization of all types (i.e., clinic visits, physician visits, and hospitalization) (Anderson, 1973;
Hershey, Luft, & Gianaris, 1975; Hulka & Wheat, 1985; Muller, 1986).
! A recent trend analysis of hospital utilization in Canada revealed that the characteristics of high users
of hospital care are those with multiple chronic conditions and elderly persons with multiple chronic
conditions and disabilities (Johansen, Nair, & Bond, 1994).
It is important to note that despite the enormous amount of literature on health care utilization no
distinction is made between necessary and excessive utilization rates. Many authors argue that this is very
difficult to measure and encourage policy makers to determine what levels of utilization have positive,
negative, or indifferent effects on the health of the population (Hershey, Luft, & Gianaris, 1975; Muller,
1986).
Prepared by Mark Morreale, BA, MSc (Epid)
September 29, 1998
References upon request
References
Anderson, J. G. (1973). Health services utilization: Framework and review. Health Services Research,
8(3), 184-99.
Barer, M. L., Evans, R. G., & Labelle, R. J. (1988). Fee controls as cost control: Tales from the frozen
North. Milbank Quarterly, 66(1), 1-64.
Hershey, J. C., Luft, H. S., & Gianaris, J. M. (1975). Making sense out of utilization data. Medical Care,
13(10), 838-54.
Hodgson, T. A. (1992). Cigarette smoking and lifetime medical expenditures. Milbank Quarterly, 70(1),
81-125.
Hulka, B. S., & Wheat, J. R. (1985). Patterns of utilization. The patient perspective. Medical Care, 23(5),
438-60.
Johansen, H., Nair, C., & Bond, J. (1994). Who goes to the hospital? An investigation of high users of
hospital days. Health Reports, 6(2), 253-77.
Muller, C. (1986). Review of twenty years of research on medical care utilization. Health Services
Research, 21(2 Pt 1), 129-44.
Rice, D. P., Hodgson, T. A., Sinsheimer, P., Browner, W., & Kopstein, A. N. (1986). The economic costs
of the health effects of smoking, 1984. Milbank Quarterly, 64(4), 489-547.