UNDERSTANDING THE CONTEXT OF HEALTH-CARE UTILIZATION - ASSESSING ENVIRONMENTAL AND PROVIDER-RELATED VARIABLES IN THE BEHAVIORAL-MODEL OF UTILIZATION

Objective. The behavioral model of utilization, developed by Andersen, Aday, and others, is one of the most frequently used frameworks for a nalyzing the factors that are associated with patient utilization of h ealthcare services. However, the use of the model for examining the co ntext within which utilization occurs-the role of the environment and provider-related factors-has been largely neglected. Objective: To con duct a systematic review and analysis to determine if studies of medic al care utilization that have used the behavioral model during the las t 20 years have included environmental and provider-related variables and the methods used to analyze these variables and potential solution s.Data Sources. The Social Science Citation Index and Science Citation Index. We included all articles from 1975-1995 that cited any of thre e key articles on the behavioral model, that included all articles tha t were empirical analyses and studies of formal medical care utilizati on, and articles that specifically stated their use of the behavioral model (n = 139). Study Design. Design was a systematic literature revi ew. Data Analysis. We use a structured review process to code articles on whether they included contextual variables: (1) environmental vari ables (characteristics of the healthcare delivery system, external env ironment, and community-level enabling factors); and (2) provider-rela ted variables (patient factors that may be influenced by providers and provider characteristics that interact with patient characteristics t o influence utilization). We also examined the methods used in studies that included contextual variables. Principal Findings. Forty-five pe rcent of the studies included environmental variables and 50 percent i ncluded provider-related variables. Few studies examined specific meas ures of the healthcare system or provider characteristics or used meth ods other than simple regression analysis with hierarchical entry of v ariables. Only 14 percent of studies analyzed the context of healthcar e by including both environmental and provider-related variables as we ll as using relevant methods.