摘要：Objectives. We estimated the prevalence and determinants of delayed and unmet needs for medical care among patients in a restructured public health system. Methods. We conducted a stratified cross-sectional probability sample of primary care patients in the Los Angeles County Department of Health Services. Face-to-face interviews were conducted with 1819 adult patients in 6 languages. The response rate was 80%. The study sample was racially/ethnically diverse. Results. Thirty-three percent reported delaying needed medical care during the preceding 12 months; 25% reported an unmet need for care because of competing priorities; and 46% had either delayed or gone without care. Conclusions. Barriers to needed health care continue to exist among patients receiving care through a large safety net system. Competing priorities for basic necessities and lack of insurance contribute importantly to unmet health care needs. The Institute of Medicine’s Committee on Monitoring Access to Personal Health Care Services defines appropriate access to health care as “the timely use of personal health services to achieve the best possible health outcome.” 1 Previous studies have found that uninsured adults are more likely to delay seeking care than those who are insured, 2– 4 less likely to receive preventive and screening services, 5 and less likely to be referred by primary care physicians for other health services. 6 Delayed or nonreceipt of medical care may result in more serious illness for the patient, increased complications, a worse prognosis, and longer hospital stays. 4, 5, 7– 9 Financial problems are only 1 of the barriers people face in obtaining the health care they need. 10 Studies support the models of health care utilization that suggest that other factors also enable or impede an individual’s ability to obtain medical care. 11, 12 These include health beliefs, cultural practices, language barriers, social networks and contacts, and the availability and accessibility of medical care in the community. 11, 12 Thus, uninsured populations composed of ethnically diverse individuals pose challenges in terms of providing/receiving needed care in a timely fashion. In many urban areas, the population is ethnically diverse with a large population of uninsured adults and children. The provision of needed medical care to low-income people residing in large urban areas continues to be a challenge. 13 For publicly funded health care systems to provide equitable access to needed health care, information about the delays patients experience in receiving care and their unmet needs for medical care is critical. The Los Angeles County Department of Health Services (LAC-DHS) serves a crucial role in the provision of health care to many adults and children in Los Angeles County, servicing more than 600 000 patients per year. Los Angeles County is remarkable for the racial/ethnic diversity of the population and for the proportion of uninsured individuals who reside there—almost 2 million in 2002. 14 In 1995, LAC-DHS faced serious financial problems that prompted restructuring of the provision of hospital-based and ambulatory care services. One major reorganizing strategy was the improvement of ambulatory care through greater emphasis on primary care services. This was implemented through the formation of partnerships between LAC-DHS and existing community clinics that served as part of the safety net. As a result of the restructuring, LAC-DHS comprised 4 types of facilities providing primary care services: comprehensive health centers, personal health centers, hospital outpatient clinics, and public/private partnership clinics. This restructuring of the ambulatory care system provided an important opportunity to assess access to health care for patients in the primary care network. We studied patients receiving primary medical care services in this system to gain a better understanding of why patients delay care or have unmet health care needs. The aims of this article are to (1) estimate the prevalence of delayed and unmet health care needs among adult patients of the LAC-DHS within the preceding 12 months, (2) identify their perceived barriers for delayed care, and (3) identify factors that put these patients at increased risk for having delayed care and unmet health care needs.
