Journal of C ommu nity Health Vol. 1, No. 2, Winter 19 7 5
A C O M P A R I S O N OF H E A L T H CARE U T I L I Z A T I O N BY H U S B A N D S A N D WIVES Agnes Chien, M.D.,* and Lawrence
J. Schneiderman, M.D.
A B S T R A C T : A c h a r t review of m a r r i e d couples seen in f a m i l y p r a c t i c e c o m p a r e d h u s b a n d - w i f e visit rates. Wives were f o u n d to utilize services significantly m o r e o f t e n : for all visits, for all visits e x c l u d i n g t h o s e r e l a t e d to p r e g n a n c y , f o r well-care visits, for p s y c h o l o g i c a l s u p p o r t yisits, a n d for s o m a t i c illness visits (including sex-related illnesses), b u t n o t for n o n - s e x - r e l a t e d s o m a t i c illness visits. T h e r e was n o significant c o r r e l a t i o n in visit-rate f r e q u e n c i e s w i t h i n h u s b a n d - w i f e pairs.
Many studies have shown that w o m e n make more use than men of a variety of health care services, including general office visits, preventive visits, consultations with specialists, home visits, and surgery) -9 A m o n g the reasons suggested for these differences are: (a) medical phenomena unique to women, e.g., pregnancy adds sex-specific needs to the usual causes for seeking medical care; (b) social factors more c o m m o n in women, e.g., n o n e m p l o y m e n t allows them more unscheduled time to consult physicians for less serious complaints or conditions; and (c) attitudes held b y w o m e n about sickness and male authority figures cause them to rely excessively on physicians for help and guidance. To investigate these hypotheses, we reviewed the charts of married couples seen in family practice and compared the visit rates b e t w e e n the husband and wife of each pair. The design of the study permitted the husband and wife to serve as matched controls for many of the variables other than sex which presumably are important in determining health care utilization, such as age, socioeconomic status, education, distance from the health care source, type of insurance, and probably also personal attitudes toward illness and health. This approach also enabled us to inquire whether the similarities in social, economic, and cultural factors, shared b y married couples, reflected on health care utilization. METHOD
The Physicians Medical charts were reviewed in the offices of three board-certified family *Tl~e authors are with the Division of Primary Medical Care, Departments of Community Medicine and Medicine, University of California, San Diego, and School of Medicine at La Jolla, California 92037. The authors would like to acknowledge the assistance of Drs. Sam Smith, Thomas Early, and Simon Brumbaugh in this study.
118
Health Care of Husbands and Wives
119
physicians w h o are m e m b e r s of a group practice in a p r e d o m i n a n t l y white, middle-class c o m m u n i t y on the outskirts of San Diego, California. The group includes nine family physicians, an ophthalmologist, a general surgeon, and an obstetrician/gynecologist, w i t h full radiological and l a b o r a t o r y support services. The physicians are Caucasian males and have been practicing with the group for 22, 18, and 13 years. A l t h o u g h each physician in the group has his o w n office, examining area, receptionist, and nursing staff, each c o n t a c t a patient makes with any m e m b e r o f the group is r e c o r d e d in the patient's chart, which is kept in a central file and is therefore available to all physicians. Thus, night calls and h o m e visits m a d e b y a covering physician, as well as consultations b y specialists, are r e c o r d e d in chronological sequence in the patient's record.
The Patients Each participating d o c t o r and his receptionist were asked to provide the names of husband-wife pairs w h o had been seen as patients by him for m o r e than five years and w h o had been living together for the same five years. No particular a t t e n t i o n was to be paid to medically " i n t e r e s t i n g " patients. The physicians provided a list of 104 couples. Letters describing the s t u d y were sent to the couples selected; 57 (55%) signed and r e t u r n e d a prepaid, preaddressed postcard granting permission for their records to be reviewed. O f these 57 couples, five were r e m o v e d f r o m the study p o p u l a t i o n because medical records of one of the couple were unavailable at the time of the review. The 52 couples remaining f o r m the basis of this report.
Data Collection I n f o r m a t i o n o b t a i n e d f r o m the charts was limited to age and o c c u p a t i o n . The basic unit of i n f o r m a t i o n was a "visit". This was defined as any episode of c o n t a c t with a physician and included after-hours care, h o m e visits, and p h o n e calls, in addition to regular office visits. T h e chief complaints and diagnoses were usually r e c o r d e d for each visit in the chart. Where t h e y were not, t h e y were e x t r a p o l a t e d f r o m the i n f o r m a t i o n in the r e c o r d e d history, physical examination, l a b o r a t o r y w o r k , and medications prescribed. The observation period generally began with that person's first visit to the physician group. For everyone, the observation period ended the day of the chart review. Preoperative and p o s t o p e r a t i v e office visits were c o u n t e d as individual visits; hospitalization itself and visits m a d e to the patient while in the hospital were e x c l u d e d f r o m the visit data. Consultations b y specialists within the group were included because c o m p l e t e notes f r o m these visits were a part o f the p a t i e n t record. Consultation visits to specialists outside the group were tabulated according to i n f o r m a t i o n contained in letters f r o m those specialists, if such were available in the chart. Wherever possible the exact n u m b e r of visits to the specialists was recorded. In eight cases, it was necessary to estimate the n u m b e r of visits made: an estimated five visits were tabulated for each of five patients (three m e n and two w o m e n ) seeing an allergist; five visits were estimated for one male seeing a urologist; five visits for a w o m a n seeing a psychiatrist; and five visits for a m a n being treated for ulcerative colitis b y an internist. N o n p h y s i c i a n c o n t a c t s were tallied separately and were not included in the calculated physician visit rates.
Data Analysis Visit classification. Whenever the nature o f the visits fell into m o r e t h a n one category, tabulation was carried o u t accordingly. Thus, a visit r e c o r d e d as " n e r v e s " and fibroid uterus was c o u n t e d one-half psychological support and one-half sex-specific visit.
120
J O U R N A L OF COMMUNITY HEALTH
1. Sex-specific visits are visits made for strictly sex-specific problems. For women, these include obstetrical visits for prenatal and postnatal care, birth control, and gynecological visits and preoperative and postoperative visits for surgery of the female genital tract. Excluded from sex-specific visits by women are visits for routine gynecological care and visits for problems of uncertain gynecological origin, such as "backaches, rule out endometriosis". Sex-specific visits for men include vasectomies, problems of the prostate, impotence, and other complaints of the male genital tract. Because impotence was counted as a partially psychological complaint, however, visits relating to impotence were counted as one-half sex-specific and one-half psychological support. 2. Sex-related visits are visits made for problems more common in one sex than in the other and include all sex-specific visits plus visits for problems, complaints, and surgery of the breast in women and all sex-specific visits plus visits for inguinal hernias in men. 3. Well-person care includes visits by well persons for routine checkups without a chief complaint recorded, visits for certification of health (e.g., premarital, insurance, employment, and driver's license examinations), and routine gynecological examinations, which are usually a part of a general physical examination. 4. Psychological support visits include: (a) visits for conditions labeled with psychiatric terms, such as depression, anxiety, and "nerves"; (b) visits for insomnia and alcoholism; (c) visits for personal or marital counseling; (d) visits related to spastic colitis, neurodermatitis, and impotence; (e) visits for menopause when there was no notation of particular somatic symptoms; (f) visits in which the notations or medications prescribed indicated the appropriateness of this category. 5. Somatic illness visits are those that were neither for well care nor psychological support and thus include all sex-specific and sex-related visits as well as non-sexrelated illness (e.g., bronchitis or diabetes) presenting with somatic manifestations. Calculation o f visits. For each person, visit rates to physicians were calculated as the number of visits per year. The number of years used to calculate the visit rate was determined by subtracting the date of the beginning of the observation period from the date of the chart review. Although this procedure maximizes usable information in each record, it tends to overestimate visit rates, when compared to sampling visits over a predetermined, arbitrary time interval. For the period of this study, however, this would probably be a negligible effect that would apply equally for b o t h husbands and wives. Visit rates between husband-wife pairs were analyzed by a one-tailed Student's t-test.
RESULTS
The Patient Population A l l b u t o n e o f t h e h u s b a n d s w e r e e m p l o y e d . D a t a w e r e less c o m p l e t e o n w i v e s ; h o w e v e r , 9 w e r e r e c o r d e d as e m p l o y e d , 12 w e r e r e c o r d e d as h o u s e w i v e s , 17 h a d c h i l d r e n y o u n g e n o u g h t o b e l i v i n g a t h o m e , 13 h a d n o occupation listed, and one was "retired". T h e h u s b a n d s ' a v e r a g e age a t t h e t i m e o f t h e f i r s t v i s i t w a s 4 0 y e a r s , 3.8 y e a r s o l d e r t h a n t h e i r w i v e s (p < 0 . 0 1 ) . M o s t p a t i e n t s s e e n w e r e b e t w e e n t h e ages o f 35 t o 5 4 .
Visit Rates Table 1 summarizes the total number
of physician contacts per year
Health Care of Husbands and Wives
121
TABLE 1 Visit Rates for All Categories by Husbands and Wives to Family Physicians (n = 7,036, Husbands = 2,647, Wives = 4,389) Visits per year Type of Visit
Wives
Husbands
Difference
P
All visits All visits, excluding pregnancy Sex-specific visits, excluding pregnancy Sex-related visits, excluding pregnancy Well-care visits Psychological support visits All somatic illness visits Somatic illness visits, excluding sex-related visits
6.6 5.9
4.4 4.4
2.2 1.5
d0.01
A C O M P A R I S O N OF H E A L T H CARE U T I L I Z A T I O N BY H U S B A N D S A N D WIVES Agnes Chien, M.D.,* and Lawrence
J. Schneiderman, M.D.
A B S T R A C T : A c h a r t review of m a r r i e d couples seen in f a m i l y p r a c t i c e c o m p a r e d h u s b a n d - w i f e visit rates. Wives were f o u n d to utilize services significantly m o r e o f t e n : for all visits, for all visits e x c l u d i n g t h o s e r e l a t e d to p r e g n a n c y , f o r well-care visits, for p s y c h o l o g i c a l s u p p o r t yisits, a n d for s o m a t i c illness visits (including sex-related illnesses), b u t n o t for n o n - s e x - r e l a t e d s o m a t i c illness visits. T h e r e was n o significant c o r r e l a t i o n in visit-rate f r e q u e n c i e s w i t h i n h u s b a n d - w i f e pairs.
Many studies have shown that w o m e n make more use than men of a variety of health care services, including general office visits, preventive visits, consultations with specialists, home visits, and surgery) -9 A m o n g the reasons suggested for these differences are: (a) medical phenomena unique to women, e.g., pregnancy adds sex-specific needs to the usual causes for seeking medical care; (b) social factors more c o m m o n in women, e.g., n o n e m p l o y m e n t allows them more unscheduled time to consult physicians for less serious complaints or conditions; and (c) attitudes held b y w o m e n about sickness and male authority figures cause them to rely excessively on physicians for help and guidance. To investigate these hypotheses, we reviewed the charts of married couples seen in family practice and compared the visit rates b e t w e e n the husband and wife of each pair. The design of the study permitted the husband and wife to serve as matched controls for many of the variables other than sex which presumably are important in determining health care utilization, such as age, socioeconomic status, education, distance from the health care source, type of insurance, and probably also personal attitudes toward illness and health. This approach also enabled us to inquire whether the similarities in social, economic, and cultural factors, shared b y married couples, reflected on health care utilization. METHOD
The Physicians Medical charts were reviewed in the offices of three board-certified family *Tl~e authors are with the Division of Primary Medical Care, Departments of Community Medicine and Medicine, University of California, San Diego, and School of Medicine at La Jolla, California 92037. The authors would like to acknowledge the assistance of Drs. Sam Smith, Thomas Early, and Simon Brumbaugh in this study.
118
Health Care of Husbands and Wives
119
physicians w h o are m e m b e r s of a group practice in a p r e d o m i n a n t l y white, middle-class c o m m u n i t y on the outskirts of San Diego, California. The group includes nine family physicians, an ophthalmologist, a general surgeon, and an obstetrician/gynecologist, w i t h full radiological and l a b o r a t o r y support services. The physicians are Caucasian males and have been practicing with the group for 22, 18, and 13 years. A l t h o u g h each physician in the group has his o w n office, examining area, receptionist, and nursing staff, each c o n t a c t a patient makes with any m e m b e r o f the group is r e c o r d e d in the patient's chart, which is kept in a central file and is therefore available to all physicians. Thus, night calls and h o m e visits m a d e b y a covering physician, as well as consultations b y specialists, are r e c o r d e d in chronological sequence in the patient's record.
The Patients Each participating d o c t o r and his receptionist were asked to provide the names of husband-wife pairs w h o had been seen as patients by him for m o r e than five years and w h o had been living together for the same five years. No particular a t t e n t i o n was to be paid to medically " i n t e r e s t i n g " patients. The physicians provided a list of 104 couples. Letters describing the s t u d y were sent to the couples selected; 57 (55%) signed and r e t u r n e d a prepaid, preaddressed postcard granting permission for their records to be reviewed. O f these 57 couples, five were r e m o v e d f r o m the study p o p u l a t i o n because medical records of one of the couple were unavailable at the time of the review. The 52 couples remaining f o r m the basis of this report.
Data Collection I n f o r m a t i o n o b t a i n e d f r o m the charts was limited to age and o c c u p a t i o n . The basic unit of i n f o r m a t i o n was a "visit". This was defined as any episode of c o n t a c t with a physician and included after-hours care, h o m e visits, and p h o n e calls, in addition to regular office visits. T h e chief complaints and diagnoses were usually r e c o r d e d for each visit in the chart. Where t h e y were not, t h e y were e x t r a p o l a t e d f r o m the i n f o r m a t i o n in the r e c o r d e d history, physical examination, l a b o r a t o r y w o r k , and medications prescribed. The observation period generally began with that person's first visit to the physician group. For everyone, the observation period ended the day of the chart review. Preoperative and p o s t o p e r a t i v e office visits were c o u n t e d as individual visits; hospitalization itself and visits m a d e to the patient while in the hospital were e x c l u d e d f r o m the visit data. Consultations b y specialists within the group were included because c o m p l e t e notes f r o m these visits were a part o f the p a t i e n t record. Consultation visits to specialists outside the group were tabulated according to i n f o r m a t i o n contained in letters f r o m those specialists, if such were available in the chart. Wherever possible the exact n u m b e r of visits to the specialists was recorded. In eight cases, it was necessary to estimate the n u m b e r of visits made: an estimated five visits were tabulated for each of five patients (three m e n and two w o m e n ) seeing an allergist; five visits were estimated for one male seeing a urologist; five visits for a w o m a n seeing a psychiatrist; and five visits for a m a n being treated for ulcerative colitis b y an internist. N o n p h y s i c i a n c o n t a c t s were tallied separately and were not included in the calculated physician visit rates.
Data Analysis Visit classification. Whenever the nature o f the visits fell into m o r e t h a n one category, tabulation was carried o u t accordingly. Thus, a visit r e c o r d e d as " n e r v e s " and fibroid uterus was c o u n t e d one-half psychological support and one-half sex-specific visit.
120
J O U R N A L OF COMMUNITY HEALTH
1. Sex-specific visits are visits made for strictly sex-specific problems. For women, these include obstetrical visits for prenatal and postnatal care, birth control, and gynecological visits and preoperative and postoperative visits for surgery of the female genital tract. Excluded from sex-specific visits by women are visits for routine gynecological care and visits for problems of uncertain gynecological origin, such as "backaches, rule out endometriosis". Sex-specific visits for men include vasectomies, problems of the prostate, impotence, and other complaints of the male genital tract. Because impotence was counted as a partially psychological complaint, however, visits relating to impotence were counted as one-half sex-specific and one-half psychological support. 2. Sex-related visits are visits made for problems more common in one sex than in the other and include all sex-specific visits plus visits for problems, complaints, and surgery of the breast in women and all sex-specific visits plus visits for inguinal hernias in men. 3. Well-person care includes visits by well persons for routine checkups without a chief complaint recorded, visits for certification of health (e.g., premarital, insurance, employment, and driver's license examinations), and routine gynecological examinations, which are usually a part of a general physical examination. 4. Psychological support visits include: (a) visits for conditions labeled with psychiatric terms, such as depression, anxiety, and "nerves"; (b) visits for insomnia and alcoholism; (c) visits for personal or marital counseling; (d) visits related to spastic colitis, neurodermatitis, and impotence; (e) visits for menopause when there was no notation of particular somatic symptoms; (f) visits in which the notations or medications prescribed indicated the appropriateness of this category. 5. Somatic illness visits are those that were neither for well care nor psychological support and thus include all sex-specific and sex-related visits as well as non-sexrelated illness (e.g., bronchitis or diabetes) presenting with somatic manifestations. Calculation o f visits. For each person, visit rates to physicians were calculated as the number of visits per year. The number of years used to calculate the visit rate was determined by subtracting the date of the beginning of the observation period from the date of the chart review. Although this procedure maximizes usable information in each record, it tends to overestimate visit rates, when compared to sampling visits over a predetermined, arbitrary time interval. For the period of this study, however, this would probably be a negligible effect that would apply equally for b o t h husbands and wives. Visit rates between husband-wife pairs were analyzed by a one-tailed Student's t-test.
RESULTS
The Patient Population A l l b u t o n e o f t h e h u s b a n d s w e r e e m p l o y e d . D a t a w e r e less c o m p l e t e o n w i v e s ; h o w e v e r , 9 w e r e r e c o r d e d as e m p l o y e d , 12 w e r e r e c o r d e d as h o u s e w i v e s , 17 h a d c h i l d r e n y o u n g e n o u g h t o b e l i v i n g a t h o m e , 13 h a d n o occupation listed, and one was "retired". T h e h u s b a n d s ' a v e r a g e age a t t h e t i m e o f t h e f i r s t v i s i t w a s 4 0 y e a r s , 3.8 y e a r s o l d e r t h a n t h e i r w i v e s (p < 0 . 0 1 ) . M o s t p a t i e n t s s e e n w e r e b e t w e e n t h e ages o f 35 t o 5 4 .
Visit Rates Table 1 summarizes the total number
of physician contacts per year
Health Care of Husbands and Wives
121
TABLE 1 Visit Rates for All Categories by Husbands and Wives to Family Physicians (n = 7,036, Husbands = 2,647, Wives = 4,389) Visits per year Type of Visit
Wives
Husbands
Difference
P
All visits All visits, excluding pregnancy Sex-specific visits, excluding pregnancy Sex-related visits, excluding pregnancy Well-care visits Psychological support visits All somatic illness visits Somatic illness visits, excluding sex-related visits
6.6 5.9
4.4 4.4
2.2 1.5
d0.01
