Effects of Individual and Contextual Factors On Perceived Quality of Healthcare Among Older Adults

Objective: This study examined patient satisfaction of community-dwelling older adults by their citizenship and nativity status. After the welfare reform of 1996, citizenship has been an important factor that determines access to healthcare and thus patient satisfaction. However, little is known about how older noncitizens’ perceived satisfaction compares with that of the U.S.-citizens and how that is affected by county-level contextual predisposing and enabling characteristics, such as the availability of healthcare providers and the proportion of foreign-born population in the counties where they live. 

 

Methods:  This study analyzed the 2000-2007 Medical Expenditure Panel Survey (individual-level data) and the linked Area Recourse File (county-level data) for 27,383 older adults (65+) from 160 counties: 1,068 noncitizens, 2,579 naturalized citizens, and 23,736 U.S.-born citizens. Two dimensions of patient satisfaction (perceived and ease of access) were examined using the Consumer Assessment of Healthcare Providers and System (CAHPS) developed by the Agency for Healthcare Research (AHRQ). Regarding ease of access, respondents were asked how often they received the care they needed as soon as they wanted (for routine care and acute care) and how much of a problem it was to see a specialist. In terms of perceived access, respondents were asked whether their health providers listened them carefully, explained things clearly, showed respect for whatever they had to say, and spent enough time with them. Finally, an overall satisfaction was assessed for all doctors and other health providers on a scale of 0 (=Worst health care possible) to 10 (=Best health care possible). According to the expanded Anderson model, individual- and contextual-level predisposing, enabling, and need characteristics were selected to examine the variation in the individual-level patient satisfaction. Multilevel models were conducted using STATA’s XTMIXED commend.    

Results: After controlling for both individual- and county-level covariates, the results indicate that noncitizens were less likely to agree that their providers spent enough time with them (p=.03) and sufficiently explained treatment (p=.01) compared with their U.S.-born counterparts.  Noncitizens’ overall rating of their providers was also lower (p<.001). Regarding ease of access, among those reported needs, noncitizens reported greater difficulties in using care after injury/illness (p<.001), routine care (p<.001), and specialty care (p=.009). In those models, county-level contextual characteristics (e.g., % of foreign-born individuals, % of uninsured, hospital bed rate in the county where respondents resided) were significantly associated with individual-level satisfaction. Interestingly, noncitizens living in the counties with high density of foreign-born population had higher satisfaction levels compared with their U.S.-born counterparts (i.e., significant interaction effect). 

 

Conclusion: The findings indicate vulnerability of older noncitizens in accessing healthcare. The findings also highlight the importance of considering where an individual lives in planning an intervention to promote patient satisfaction and quality of care. The significant interaction between citizenship status and county-level characteristics indicate the needs for targeted community-based interventions for older noncitizens.