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Access to Health Care, Socioeconomic Status, and Health
- Leigh F. Callahan, PhD; and
- Theodore Pincus, MD
- University of North Carolina; Chapel Hill, NC 27599 (Callahan) Vanderbilt University; Nashville, TN 37232 (Pincus)
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
IN RESPONSE:
We appreciate the comments of Dr. Baltzan, which provide us an opportunity to reemphasize our strong belief in the importance of access to medical care to improve health outcomes (1). Access to care is more critical to outcomes in acute diseases and acute events within chronic diseases but becomes less critical in outcomes of chronic diseases.
We would broaden the meaning of the term “access” beyond its generally understood meaning, which involves removal of financial barriers to standard medical encounters. For example, might “access to care” not include such matters as transportation to a clinical site, provision for continuity with the same physician (if desired), patient education, programs to enhance self-management, and family therapy? Many additional approaches to “access” seem to be required if one is to take full advantage of scientific medical advances, particularly for persons of lower socioeconomic status.
Although decreases in mortality during the 1970s “coincided with dramatic improvements in access to care,” that phenomenon does not establish cause and effect. For example, the decrease in tuberculosis deaths in the first half of the 20th century, when antibiotics were not available, did not substantially differ from that seen in the second half of the century, when antibiotics were used (2, 3). Furthermore, concomitant increased longevity and increased unemployment are not inconsistent with associations of socioeconomic status and health and may be explained by evidence of widening disparities in mortality according to socioeconomic status (4). In addition, it can be argued that improvements in outcomes for stroke, myocardial infarction, and vehicular trauma and neonatal survival result from improved social conditions rather than from direct medical care; similar higher prevalences according to socioeconomic status are seen in all these conditions (5).
We agree with Dr. Baltzan's conclusion that access, social conditions, and self-management are all relevant to care. All physicians have some patients whom they recognize will do very well and others whom they recognize will probably have poor outcomes. We suggest that primary determinants of this overall prognostic impression are variables identified with socioeconomic status, regardless of access to care. Access is certainly important as a necessary condition to improved health; however, it is sufficient in acute diseases but not sufficient in chronic diseases, in which self-management and social conditions may be as (if not more) important.
Leigh F. Callahan, PhD
University of North Carolina; Chapel Hill, NC 27599
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
