Factors Explaining the Use of Health

Care Services by the Elderly

Connie Evashwick, Genevieve Rowe, Paula Diehr,
and Laurence Branch

The Andersen model of health services utilization, which relates use of service to
predisposing, enabling, and needfactors, has not often been applied to an elderly
population. In this study, thefactors of the Andersen model were usedprospectively
to predict utilization for a population sample of 1,317 elderly persons. Taken
alone, the NEED construct was the most important single predictor of use of
physician services, hospitalizations, ambulatory care, and home care. PREDIS-
POSING factors were better predictors of the use of dental services. Some of the
variables studied were not related to utilization in the direction that would have
been predictedfrom previous studies on general populations. Multivariate analyses
demonstrated that the three constructs should be applied simultaneously when
predicting use of services. These findings can be applied to the specific task of
planning services for older people.

The dramatic changes occurring in the age structure of American

society make providing services for the elderly a major challenge to
health care professionals. In 1900, only 4 percent of the population was
age 65 or over [1]. Today, about 11 percent of our population falls in
that category [2], and current projections indicate that by the year 2000
as much as 15 percent of the nation's population will be age 65 or older
[3]. Furthermore, the cohort of persons age 75 and over is the single
fastest-growing age group [4].
The elderly are disproportionate users of the health care system.

Connie Evashwick is Vice-President for Long-Term Care, Pacific Health Resources in

Los Angeles; Genevieve Rowe is a Research Associate with Compass Consulting in
Bellevue, Washington; and Paula Diehr is an Associate Professor in the Department of
Biostatistics, University of Washington, Seattle. Address all communications and
requests for reprints to Dr. Laurence Branch, Associate Professor and Director of
Massachusetts Health Care Panel Study, Harvard Medical School, 643 Huntington
Avenue, Boston, MA 02115.
358 Health Services Research 19:3 (August 1984)

They average 6.1 visits per year to a physician, compared with 4.1
visits per year by adults age 45-64 [5]. They have more hospital admis-
sions and longer lengths of stay than any other age group [6]. Also, 5
percent of those age 65 or older reside in nursing homes, occupying 90
percent of all long-term care beds in the United States [7]. In terms of
expenditures for health care, 30 percent of the monies spent on per-
sonal health care are by persons age 65 or older [8]. Eight percent of all
personal health dollars spent by older people are for nursing home
care.
Social services for older adults have increased markedly in recent
years, due to greater societal awareness of their needs and the resulting
federal and state funding for an array of services. With the 1965 pas-
sage of Medicare, Medicaid, and the Older Americans Act, the federal
government assumed the responsibility for funding health and social
services for those individuals age 65 and over. Trends in the use of
services and dollars spent indicate that older people are, indeed, receiv-
ing care. Lobbying groups for older Americans and those working in
the field of gerontology continue to advocate the provision of improved
health and social services.
Current reductions in federal, state, and local budgets will result
in the curtailment of public support for some of these services for older
people. To achieve a balance between the demand for services and the
resources available to provide them, efficiency is needed in the plan-
ning and development of health services. Despite years of discussion on
issues pertaining to "long-term care," the methodology for determining
the appropriate mix of services required by an older population is not
well developed.
Many of the data on the use of health services by older adults focus
on the recipients of a specific service. For example, extensive informa-
tion is available on the characteristics of nursing home residents and
the recipients of Medicare-reimbursed home care, as well as on the
diagnostic conditions of those age 65 and over admitted to a hospital.
Numerous studies have analyzed the use of health services by a select
subgroup, such as the participants in model projects for low-income
public housing residents. Few studies, however, have focused on a
random sample of persons age 65 and above to determine the range of
services used over time and the respective characteristics of the users.
Research on the utilization of health and social services by older
people has identified a set of variables associated with use. However,
few studies have been methodologically rigorous in examining the
interrelationships of the independent variables; most stop with correla-
tions of the independent and dependent variables. Nor have many
 Elderly and Health Care 359

studies been undertaken to compare the relative importance of the

independent variables in explaining the use of different types of health
services.
Leading gerontologists contend that the older population is highly
heterogeneous. Similarly, researchers and providers of long-term care
are adamant in pointing out that not all services are appropriate for all
older people. A great deal of effort has been devoted to developing
assessment instruments, which are used for individual care plans and
reimbursement calculations - but not for projecting the demand for
services. To plan services for a population, a methodology is required
that takes into consideration characteristics of various subsamples and
a range of service options.
An array of raw data are available from census, health interview
survey, state licensing, and vital statistics reporting, but these data may
not be detailed enough to permit utilization projections at a local level.
Before extensive efforts are made to gather additional data, it is imper-
ative to know which data are most pertinent to the planning issues at
hand.
The purpose of the study reported in this article was to identify the
factors important in explaining the use of various services by a random
sample of older adults and to examine the interrelationships of these
variables. By using multivariate analyses, the study enabled us to iden-
tify the factors most important in explaining and predicting the use of
different services. The findings are intended to be useful to those plan-
ning and developing services for older adults and to those involved in
forming institutional and public policies.
Research on the health care delivery system has identified a num-
ber of factors related to the use of health services. Andersen and col-
leagues have formulated a model that incorporates many of these fac-
tors in specified relationships. We chose this model as the basis of our
study.

METHODS OF DATA COLLECTION

In 1974, the Massachusetts Department of Public Health initiated a
series of studies to identify services which could be provided by the
Health Department to maximize the quality of life of older persons
while minimizing costs. Particular emphasis was placed on determin-
ing the need for nursing home versus other services. The goal of the
department was to foster independence and enable elderly persons to
360 Health Services Research 19:3 (August 1984)

remain in their homes and communities rather than going into nursing
homes.
The Massachusetts Health Care Panel Study began in 1974, and
the first follow-up survey was conducted in 1976. The survey instru-
ment focused on the respondents' ability to perform the basic activities
of daily living with or without assistance, current use of health and
social services, and perceived need for social support and health care.
The descriptive findings of the two surveys have been presented else-
where [9-10].
The Andersen model of health services use is based on characteris-
tics of the population at risk, the resources of the health care system,
and utilization [11]. The population at risk is characterized by predis-
posing, enabling, and need factors. Utilization includes the type, site,
purpose, and time interval of services used. Resources include the
volume, distribution, and organization of health care providers and
provider organizations.
Length and time limitations of the questionnaire did not permit
collection of data on all variables specified by the Andersen model.
However, the variables included in the instrument were sufficient to
permit the application of the model to predict and explain the use of
health and related services by older adults. PREDISPOSING and
ENABLING variables came primarily from standard questions about
demographic and economic characteristics. NEED variables came
from a modified Katz scale [12], a modified Rosow-Breslau scale [13],
self-reported health status, and self-reported problematic physical con-
ditions. The six measures of utilization were Physician Visits, Hospi-
talization, and Nursing Home, Dental, Ambulatory Care, and Home
Care services. The latter two were comprised of several types of care.
Measures of system resources were not included in this data set.
The PREDISPOSING, ENABLING, and NEED variables were
taken from the 1974 survey. They were used to predict the utilization
variables from the 1976 follow-up survey. The variables used in this
study and their operational definitions are given in Table 1.
The respondents for the survey were drawn from a statewide area
probability sample of households. Residents of nursing homes or other
institutions were not eligible. A total of 8,614 households were selected.
All individuals of age 65 or older were interviewed, which produced
1,625 respondents. The sample was reinterviewed 15 months later. Of
the 1,625 original respondents, 1,466 participated in the second wave,
including 1,317 who completed interviews. Details of the sampling and
interview procedures have been presented elsewhere [10,14]. Table 2
presents the distribution of the sample respondents by age, sex, and
race. These are similar to national figures for the elderly.
 Elderly and Health Care 361

METHODS OF DATA ANALYSIS

The purpose of the study summarized here was to determine the extent
to which the utilization of different types of health care services (i.e.,
each of the six dependent variables) could be predicted by the three
categories of independent variables specified by the Andersen model
and to ascertain the relative importance of each independent variable
in predicting the use of each service. This would enable those project-
ing the demand for services to be selective in the collection of data
necessary for planning.
In an earlier paper, the relationships between the dependent and
independent variables were examined by use of multiple regression
analysis performed on the cross-sectional data from the first survey
[15]. Our study advances the previous work in two ways. First, inde-
pendent variables from Time 1 are used to predict utilization variables
from Time 2, thus emphasizing the predictive, rather than associative,
use of available PREDISPOSING, ENABLING, and NEED data.
Second, the analysis is extended by use of principal component analysis
to create a single index to represent each construct in the Andersen
model. This simplification allows us to look at the relationships among
the three constructs in a more interpretable form.
The analysis was conducted in four steps. First, the zero-order
correlation coefficients between the independent and the dependent
variables were calculated to explore the relationships between individ-
ual variables and utilization. Second, multiple regression analysis was
used to predict each utilization measure as a function of all 20 varia-
bles. Third, the 20 variables were divided into subgroups representing
NEED, PREDISPOSING, and ENABLING, and the multiple regres-
sion analysis was repeated using only one set of variables at a time. The
R2 measures from each regression were compared to the total R2
obtained when all 20 variables were used and to the R2 obtained from
each of the other two sets of independent variables. This showed the
relative importance of each set of variables in explaining a given depen-
dent variable.
Finally, an index was created from each set of independent varia-
bles so that each construct was represented by a single variable rather
than by six or seven separate variables. This made it easier to see the
direction of the relationship between each construct and the utilization
measures, and it simplified examination of the relationships among the
constructs. The first principal component of each group of variables
was chosen as the index. This step of the analysis is discussed in more
detail later.
We then examined the relationship of each of these indexes to the
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Table 2: Age, Sex, and Race

of Sample Respondents
Age: 65-69 36.2%o
70-74 27.4%
75-79 19.7%
80 + 16.7%
Sex: Female 61.7%
Male 38.3%
Race: White 99.0%
Nonwhite 1.0%

six utilization variables, separately and together, using multiple regres-

sion. This revealed the effect of each construct on utilization while
controlling for the other constructs. The results of the analyses were
summarized to make a general statement about the relative effects of
NEED, PREDISPOSING, and ENABLING factors on utilization of
health services by the elderly. These analyses are available in greater
detail from the authors [16].

FINDINGS
UTILIZATION OF SERVICES
The overall levels of service utilization are shown in Table 3. Eighty-
two percent of the respondents reported seeing a doctor during the 15-
month interval between the initial and follow-up surveys. This is con-
sistent with the data of the National Health Interview Survey. Nearly
one-third of the respondents had seen a dentist within the past 15
months. About one-fifth had been admitted to a hospital. These find-
ings are also what would be expected based on national data.
Very few persons reported using other types of health or health-
related services. At most, 4 percent of the respondents had used any
rehabilitation services, counseling services, speech therapy, hot meals,
visiting nurse service, homemaker or home health aide, or other special
care. The low utilization rates for such services are in themselves
revealing.
The small number of persons using these types of auxiliary and
support services placed some limitations on further data analyses.
Rather than analyzing each service separately, the services were com-
bined into two variables: the Home Care variable, which included
 Elderly and Health Care 365

Table 3: Utilization of Services

Percentage of Respondents
Using Services During
Service Preceding 15 Months
Physician services 82.4
Dental services 31.8
Hospital services 22.0
Nursing home services 1.1
Ambulatory care services
Speech therapy 0.5
Rehabilitation therapy 2.8
Professional counseling 0.8
Home care services
Nursing services 4.0
Hot meal service 1.2
Homemaker/Home health aide service 2.3
Special care services 4.0

visiting nurses, homemaker, home health aide, hot meals, and special
care, and the Ambulatory Care variable, made up of rehabilitation
therapy, speech therapy, and professional counseling.
CORRELATIONS BETWEEN INDIVIDUAL VARIABLES
AND UTILIZATION
Table 4 presents the zero-order correlations between each PREDIS-
POSING variable and each utilization variable. Rather than present
numbers, the direction of each relationship is shown, and the statistical
significance of the relationship is indicated by asterisks. For example,
examining the variable AGE: older people used more Physician Ser-
vices, more Hospital Services, .and more Ambulatory Care Services;
significantly more Nursing Home and Home Care Services; and sig-
nificantly fewer Dental Services. PREVENT (seeing physician on a
regular basis rather than on a problem basis) is significantly related to
more of the utilization variables than any of the other PREDISPOS-
ING measures, and dental services is significantly related to more of
the PREDISPOSING variables than any of the other utilization mea-
sures. Some discrepancies between these results and the Andersen
model appear: those with more education used fewer physician and
home care services and whites used fewer home care services.
Table 5 presents similar information for the ENABLING varia-
bles. The Andersen model would predict that the more "able" would
use more services, but in many cases a relationship is found in the
366 Health Services Research 19:3 (August 1984)

Table 4: Relationships between PREDISPOSING Variables

and Utilization Variables
Nursing Ambulatory Home
Physician Hospital Home Care Care Dental
Services Services Services Services Services Services
AGE
Older use more more more* more morel less t
SEX
Females use more* less more more more more*
RACE
Whites use more more more more lesst less
EDUC
Higher use less* less more less less* morel
ALONE
Live alone use less more less less less more
MARRIED
Married use less more less less* less* more
WDS
Widowed use more more more more more lesst
Divorced use more less more more more less
Separated use less less less less less less
PREVENT
Have reg.
visits use moret morel less* morel more morel
*p < .05.
tp . .01.

opposite direction. This is particularly true of TRANSPO, which is

significantly related to all of the utilization variables except dental
services, in the "wrong" direction. VAINS (Veterans Insurance) is not
significantly related to any of the utilization variables, and hospital and
nursing home services are not significantly related to any but the
TRANSPO variable (in the wrong direction). These discrepancies
might, of course, be caused by confounding of these ENABLING
variables with age, health status, and income, suggesting that a multi-
variate analysis is needed to control for some of these other variables.
Table 6 presents the information for the NEED variables. Here,
nearly every variable is significantly related to utilization. The major
discrepancy is for dental services, in which the more "needy" tended to
have fewer services rather than more. As above, multivariate analysis
is needed to remove the effect of possible confounding factors.
 Elderly and Health Care 367

Table 5: Relationships between ENABLING Variables and

Utilization Variables
Nursing Ambulatory Home
Physician Hospital Home Care Care Dental
Services Services Services Services Services Services
OCCUP
White collar use less more more more less morel
INCOME
Higher use less less less less less$ morel
MEDICAID
With use morel more less more* moret lesst
VAINS
With use more more less less less less
PRIVINS
With use more more less more more less t
OWNDOC
Have use morel more more less less more
TRANSPO
With no problems
use lesst less* less* lesst lesst more*
*p .05.
lp < .01.

Table 6: Relationships between NEED Variables and

Utilization Variables
Nursing Ambulatory Home
Physician Hospital Home Care Care Dental
Services Services Services Services Services Services
HLTHSTAT
Poorer use morel morel morel morel morel lesst
PHYSACT
Problem use morel moret more morel morel less$
STAIRS
Problem use morel morel morel morel morel less$
WALK'/2MIL
Problem use morel morel morel morel morel lesst
PHYSCOND
Have use morel morel more morel morel less$
ADLFUNC
Poorer use moret moret moret morel morel less
tp < .01.
368 Health Services Research 19:3 (August 1984)
MULTIPLE REGRESSION PREDICTING UTILIZATION
FROM INDIVIDUAL VARIABLES
Table 7 shows the R2, or proportion of variance reduction, when all 20
variables were included in a multiple regression equation to predict
each of the utilization measures. Nearly 24 percent of the variability in
Physician Services was explained, but only about 3 percent (not statis-
tically significant) of the variability in Nursing Home Services was
explained by the 20 variables.
The last three lines in Table 7 show the R2 achieved when only
variables from a given subset were used to predict utilization. For
example, the PREDISPOSING variables taken alone explained 10.5
percent of the variability in Physician Services, compared to 6.3 per-
cent explained by ENABLING variables and 16.5 percent explained
by the NEED variables. No equation was statistically significant for
Nursing Home Services, and only NEED variables were significantly
related to Hospital and Ambulatory Care.
In most cases, the NEED variables explained more of the variabil-
ity than did the other two categories. The major exception was Dental
Services, where the PREDISPOSING and ENABLING variables
accounted for more of the variability than the NEED variables.
The amount of variability accounted for by PREDISPOSING
and ENABLING variables was about the same for all utilization mea-
sures except Physician Services, where the PREDISPOSING variables
were substantially better predictors than the ENABLING variables.
Table 8 shows the variables which were chosen by forward selec-

Table 7: Squared Multiple Correlation Coefficients (R2) of

Variables in the NEED, PREDISPOSING, and ENABLING
Groups Predicting Six Utilization Variables
Utilization Variables
Independent Nursing Ambulato?y Home
Variable Physician Hospital Home Care Care Dental
Groups Services Services Services Services Services Services
All Variables
(N = 839) + .2363* .0623 .0345 .0717* .1348* .1054*
PREDISPOSING
(N = 1199) + .1052* .0073 .0134 .0093 .0365* .0865*
ENABLING
(N = 1065) + .0631 * .0127 .0074 .0110 .0352* .0712*
NEED
(N = 1069) + .1648* .0452* .0122 .0423* .1190* .0277*
*Significant, p < .001.
N + changes because of missing data.
 Elderly and Health Care 369

tion regression analysis with F-to-enter set at 4.0. This analysis was
performed three times, once for the variables from each of the con-
structs. In most cases only one or two variables were chosen from each
construct. Among the PREDISPOSING variables, Preventive, Age,
and Marital Status were chosen more often than the others; Sex and
Household Composition were never chosen. Among the ENABLING
variables, the two variables chosen most often were Transportation and
Medicaid. Veterans Insurance, Private Insurance, and Medicare were
not chosen for any of the utilization measures. Among the NEED
variables, Health Status was chosen most frequently, and the presence
of a Physical Condition and Problems in Climbing Stairs were also
chosen frequently. The Inability to Walk Half a Mile was chosen only
as a predictor of Hospitalization.
The directions of the relationships shown in Table 8 were quite
similar to those shown in Table 6, which presented the univariate
relationships of the PREDISPOSING and utilization variables. These
findings were also generally consistent with what would be expected
based on previous studies. However, older people had fewer Dental
Services; the predisposition to see a physician on a regular basis rather
than on a problem basis (PREVENT) was negatively associated with
Nursing Home Services; and whites had fewer Home Care Services.
Among the ENABLING and NEED variables, all relationships
remained the same in the multiple regression results as in the correla-
tion results. Again, people with Transportation problems used signifi-
cantly more services, which does not agree with the Andersen model.
The relationships among the independent variables and Dental utiliza-
tion were consistently in the opposite direction from the relationships of
the other utilization variables. This will be discussed in some detail
later.
As has been noted, some variables were significant predictors of
utilization but not in the direction expected based on current theory. It
seemed inappropriate to make statements about the relative strengths
of constructs when some of the variables making up the constructs were
not acting according to expectations. To address this problem, we
reduced each of the three sets of independent variable constructs to a
single index, making it easy to see the direction of any effects. The use
of a single index rather than many individual variables also facilitated
comparison of the constructs.
The method of principal components [17] was used to determine a
single "best" index from each set of variables. This index is a weighted
sum of the individual variables, which has maximal correlation with
the individual variables. Thus, if the variables have something in com-
370 Health Services Research 19:3 (August 1984)

Table 8: Significant Variables from Stepwise Regression*

Predicting Utilization
Nursing Ambulatory Home
Physician Hospital Home Care Care Dental
Variabkls Services Servies Servie Srvices Sevices ervices
PREDISPOSING:
AGE (older) more less
EDUC (more) more
PREVENT (yes) more more less more
MARRIED less less
WDS less
RACE (white) less
ENABLING:
INCOME (higher) more
MEDICAID (have) more more
OCCUP
(white collar) more
OWNDOC (have
doctor) more
TRANSPO
(no problems) less less less less
NEED:
PHYSACT
(problems) more
STAIRS
(problems) more more more
WALK1/2MIL
(problems) more
HLTHSTAT
(worse) more more more more less
FUNCSTAT
(poorer) more
PHYSCOND
(if any) more more more
*F-to-enter was set at 4.0.

mon (e.g., they are all measures of "need"), then the resulting index
will also be a measure of "need," and will account for more of the
information in the original set of variables than will any other such
index.
The Andersen model does not state that each of the three con-
structs should be reducible to a single dimension; however, this "best"
index will be a good representation of the construct if the original
 Elderly and Health Care 371

variables share the property of being related to the underlying con-

struct. If some of the original variables are not highly correlated with
the resulting index, this suggests that for some reason they are not
highly correlated with the other variables in the construct.
This does not invalidate the index but suggests that the "omitted"
variables are not related to the construct as predicted. This could
happen because the variable is more related to some other factor than
to the construct, or because it represents a different dimension of the
construct than the dimension being represented by the index. These
points will be illustrated in the following description of the three
indexes.
The NEED index will be discussed first, since it is the easiest to
understand. Principal component analysis of the six NEED variables
resulted in the index:
NEED = .50(PHYSACT) + .91(STAIRS) + .65(WALK1/2MIL)
+ .27(HLTHSTAT) + .29(ADLFUNC) + .42(PHYSCOND)
This index accounted for 48 percent of the variability in the origi-
nal six variables and, therefore, provided a reasonable summary of the
information available on a person's self-reported health status and
inferred need for care. As the signs of the coefficients of each variable
indicate, the NEED index became larger for sick people and smaller for
healthy people, and was thus a good representation of the construct
NEED. Each of the individual variables was correlated approximately
0.7 with NEED, which was further validation that the index was a
measure of need.
Analysis of the ENABLING group was less satisfactory. This
might have been expected since such diverse factors as income, insur-
ance, type of occupation, having a regular doctor, and difficulty with
transportation were all included in this group. The first principal com-
ponent was:

ENABLE = + .09(INCOME)-.75(MEDICAID)-.34{VAINS) + .77(PRIVINS)

- .73(OCCUP) - .07(OWNDOC) - .34(TRANSPO)
This index accounted for 24 percent of the variability in the seven
ENABLING variables. It was not highly correlated with Veterans
Insurance or with Having a Particular Physician. A reason for the
former could be the small number (2.3 percent) of respondents who
have veterans insurance. The relationship of OWNDOC to the other
ENABLING variables is discussed later. Based on the signs of the
statistically significant relationships, people with a low value on this
372 Health Services Research 19:3 (August 1984)
index tended to have low income, to be on Medicaid, to have no
private insurance, to be blue-collar workers, and to have difficulty in
obtaining transportation. Except for the low correlation with the two
variables mentioned above, this index had face validity as a summary
of the ENABLING factors.
Finally, the seven PREDISPOSING variables were analyzed.
The resulting index was:
PREDISPOSING = .1 (AGE) - .39(SEX) - .02(EDUC) + .05(PREVENT)
- .71(MARRIED) + .70(WDS) + .16(RACE)
+ .64(ALONE)

The index accounted for 33 percent of the variability in the eight

PREDISPOSING variables. The signs of the coefficients show that a
person who is older, female, not married, who is divorced, widowed or
separated, and who is living alone, less educated, white, and seeing a
physician only for problems would have higher values on this index.
The signs of most of the variables were in the expected direction,
suggesting that this was indeed an index of the predisposition to use
services.
Three of the variables were not significantly correlated with the
new index (Race, Education and Prevention). The fact that Race is not
represented by the index seems a small loss since virtually all of the
respondents were white. The fact that Education and Prevention are
not represented by the index is unsatisfying, especially since PRE-
VENT was often the first PREDISPOSING variable chosen in
stepwise regression. Thus, although the index had face validity as a
measure of the construct PREDISPOSING, it did not offer a good
representation of all of the variables in the group.
It may be that predisposition (as operationalized here) is not a
simple construct and cannot be represented by a single underlying
dimension. The principal component analysis showed that two indexes
would be required to account for 43 percent of the variability in the
PREDISPOSING variables, and that a third index would bring this up
to 57 percent. To explore the dimensionality of the PREDISPOSING
construct further, the first three principal components, all of which had
eigenvalues greater than one, were orthogonally rotated. The resulting
factors did emphasize three different components of the PREDISPOS4
ING construct. The first factor had high loadings for ALONE, MAR-
RIED, WDS, and SEX; the second factor had high loadings for AGE
and EDUCATION; and the third factor had a high loading for PRE-
VENT. Race never loaded on any of these factors, which- may be due
 Elderly and Health Care 373

to the low number of nonwhites in the sample. Adding these additional

factors would have defeated the objective of the index construction,
which was to reduce the number of independent variables. For this
reason, only the first principal component was used in the following
analyses since it is a representative of PREDISPOSING factors and
has some optimal properties.
Table 9 shows the relationships among the three indexes for the
887 persons for whom complete information was available on all of the
variables. All three indexes were significantly intercorrelated. ENA-
BLING was negatively correlated with both PREDISPOSING and
NEED, showing that subjects who were less "able" had more PREDIS-
POSING factors and more NEED. Those subjects with more PRE-
DISPOSING factors also had more NEED. These interrelationships
suggest that multivariate analysis is necessary to identify individual
contributions of the constructs.
Table 10 shows the zero-order correlations between the three
indexes and the six utilization variables. Physician Services, Hospital
Services, and Ambulatory Care had significant positive correlations
with the NEED index, but were not significantly correlated with the
other indexes. Nursing Home Services had a significant positive corre-
lation with both the PREDISPOSING and the NEED indexes. Home
Care was related negatively to the ENABLING factor and positively to
the NEED factor. Dental Services had a significant positive correlation
with the ENABLING index and was negatively correlated with the
NEED index.
The NEED index was significantly related to all of the utilization
measures: the "needy" had fewer dental services and more of the other
five types of utilization. This is similar to the results found earlier for
the regressions using the sets of variables (Table 8).
The ENABLING index was not significantly related to Physician
Services, Hospital Services, Nursing Home Admissions, or use of
Ambulatory Care. The subjects who were the least "able" to obtain
-services were significantly more likely to haye Home Care services. The
more "able" subjects were significantly more likely to have Dental care.
The PREDISPOSING index was significantly correlated only with
Nursing Home Services, with those "predisposed" using more.
Table 11 shows the results of stepwise regression using the three
indexes in a single equation to predict the six dependent variables. The
results are very similar to those of Table 10. For Hospital Services,
Ambulatory Care, and Home Care, NEED was the only independent
variable entering the equation. Both the NEED and PREDISPOSING
indexes were important in explaining Nursing Home use, and the
374 Health Services Research 19:3 (August 1984)

Table 9: Zero-Order Correlations between PREDISPOSING,

ENABLING and NEED Indexes (N = 887)
PREDISPOSIG ENABLING NEED
PREDISPOSING 1.0
ENABLING -.30* 1.0
NEED .10* -.35* 1.0
*p > .067 is significantly different from zero.
PREDISPOSING: High value means old, female, divorced, lives alone.
ENABLING: High value means more able, e.g., higher income, more
insurance.
NEED: High value means more health problems and sicker.

Table 10: Zero-Order Correlations between Three Indexes and

Six Utilization Measures (N = 887)
Nursing Ambulatory Home
Physician Hospital Home Care Care Dental
Services Srvices Services Services Sevices Services
VDDPThZD1CQTW0 nn1 _ Al % ARA* A'%7 (91
1.
. %/ - . Al
- VJ1
ENABLING -.041 -.039 -.0'30 -.016 -. 103* .257*
NEED .349* .193* .Ot31 * .187* .274* -.117*
*p > .067 is significantly different from zero.

ENABLING index was significantly related to Dental Services. For

Physician Services, NEED was significant, as in the zero-order correla-
tion findings. However, the coefficient for the ENABLING index also
became positive and significant after controlling for NEED, indicating
that those persons who were more "able" did have more visits. The
apparent negative relationship between Physician Services use and
ENABLING found in Table 10 occurred because the "less able" were
also "more needy." The other change from the simple correlations was
that NEED was no longer a significant negative predictor of Dental
Services use after controlling for ENABLING. The apparent negative
relationship between NEED and Dental Services occurred here
because the less needy were more able, and the more able used more
dental services. The NEED and ENABLING indexes thus tended to
show inverse relationships with the dependent variables when the rela-
tionships were examined independently. When examined simultane-
ously, however, the nature of the relationships became clearer. Thus,
the multiple regression analysis of the indexes clarified some of the
apparent discrepancies found in the other analyses.
 Elderly and Health Care 375

Table 11: Significant Relationships from Stepwise Regression*

Using Indexes to Predict Utilization
Nursing Ambulatory Home
Physician Hospital Home Care Care Dental
Services Services Services Services Services Services
PREDISPOSE more
ENABLE more more
NEED more more more more more
*F-to-enter was set at 4.0.

At this point in the analysis, the interactions of the three indexes

were examined. The regression analysis using the three indexes to
predict the six utilization measures was repeated and, after controlling
for the main effects, the first-order interactions were allowed to enter
the equation in a stepwise manner. The only significant interaction was
that of ENABLE and NEED as a predictor of Dental Services. The
direction of this relationship is consistent with what was previously
discovered; those less needy and more able used more dental services.
We were also interested in whether the relationships between the
indexes and the measures of use would hold if the regression analysis
was repeated; once, using those respondents age 65-74, and again,
using those age 75 and older. The results were the same with respect to
the direction of associations. Some relationships were no longer signifi-
cant, but this was due to a large decrease in sample size and not to a
change in the magnitude of the association.
Several times during the analysis, questions arose regarding the
appropriateness of the three groups of variables. The principal compo-
nent analysis suggested more than one underlying dimension for both
the ENABLING and PREDISPOSING constructs. To address this
issue, factor analysis was performed using the variables from the three
constructs combined into one group. If NEED, PREDISPOSING,
and ENABLING are the underlying constructs being measured, we
would expect the variables to factor into three groups, each with high
loadings for the variables in one group. In fact, five factors were identi-
fied, which explained 56.6 percent of the total variation among all of
the variables.
The first factor clearly measured NEED. There were high positive
loadings for all of the variables in this group. In addition, there was a
high positive loading for Transportation. It seems that the Transporta-
tion variable measures problems in getting to a health care location in
terms of functional status and not as an ENABLING characteristic.
376 Health Services Research 19:3 (August 1984)

This variable was associated with the dependent variables in the same
way as the NEED variables were in the correlation and regression
analyses.
The second factor consists of several of the PREDISPOSING
variables: ALONE, MARRIED, WDS, and SEX. The third factor
has high loadings for both PREDISPOSING and ENABLING varia-
bles that pertain to socioeconomic status (SES): EDUCATION,
OCCUPATION, INCOME, and PRIVATE INSURANCE.
HEALTH STATUS is also represented here. High values for this fac-
tor are obtained for those who are more educated, have higher
incomes, have held white-collar jobs, have private health insurance,
and enjoy better health status. The significant loading for HEALTH
STATUS is not inconsistent with the accepted theory that those with
higher SES have better health status.
The fourth factor represents those who have a regular source of
care (OWNDOC), have regular visits (PREVENT), and do not have a
condition that bothers them (PHYSCOND). This seems to describe
preventive behavior.
RACE and VETERANS INSURANCE were omitted from all
factors since they represented such small subpopulations.
Clearly some variables belonged with a different group, an.d some
groups should have been separated into two or even three groups. For
this sample, the constructs apparently defining the population at risk
are: "Need," "Living Situation," "Socioeconomic Status," "Preventive
Behavior," and "Age."

IMPORTANCE
Due to the large sample size, the study produced many results which
were statistically significant while having small R2 values. Since "statis-
tical significance," "size of R2," and "importance" are often confused, we
have constructed a simplified example. Table 12 shows the results of
predicting Hospital Utilization from the presence of Physical Condi-
tions (R2 = .03); Physician Services from Health Status (R2 = .11);
and Dental Services from Usual Occupation (R2 = .05). All of these
regressions were statistically significant, although the R2 values were
small.
The fourth column of Table 12 shows the average utilization rates
obtained in the survey. The fifth column contains the estimated utiliza-
tion rates for different levels of the independent variables. The final
column presents 95 percent confidence intervals for differences in those
levels.
 Elderly and Health Care 377

The differences are impressive, despite the fact that the R2 is not
large. For example, the hospital admission rate, which was 216 per
thousand overall, was 280 per thousand for people with a physical
problem, compared to only 130 per thousand for those without. The
difference between these two groups is 150 per thousand and this
difference has a 95 percent confidence interval from 100-200 admis-
sions. Thus, we are 95 percent confident that in the large population
from which these data are a sample (i.e., persons over age 65 living in
the community), the hospitalization rate for the one group is at least 100
admissions per thousand higher than for the other.
For people in "excellent" health, the Physician Visit rate was esti-
mated at 1.9, while for those in "poor" health, the rate was 6.6 visits.
The 95 percent confidence interval for the difference between "excel-
lent" and "poor" health is 3.9-5.6 visits per year, again an important
consideration for planning purposes. With respect to annual dental
services, the mean is .32 per person; but it is .45 for white-collar
workers versus .24 for blue-collar workers. The 95 percent confidence
interval for the difference is .15-.27 dental visits per year. Thus, the
difference between the occupation groups in total dental visits would
seem to be very large.
A low value of R2 shows that we cannot do a good job of predicting
the utilization of an individual from these data. In aggregate, however,
we can predict average utilization in population subgroups with con-
siderable confidence. The factors identified in this analysis are thus
important as well as statistically significant, despite the low R2 values
obtained.

DISCUSSION
The purpose of the study described in this article was to try to identify
the factors explaining utilization of health and social services by older
people. This identification would provide information enabling us to
develop a methodology that could be used in developing a rational base
upon which to plan services for the older population. The findings on
utilization are in themselves interesting: in general, the older popula-
tion residing in the community made minimal use of any services other
than physician care and hospital care.
The simple correlation of the independent variables related to
utilization showed several noteworthy patterns. Of the PREDISPOS-
ING variables, which are basically demographic characteristics, no
single factor was consistently a statistically significant predictor of utili-
zation of the six categories of service.
378 Health Services Research 19:3 (August 1984)
Most of the relationships tended to move in directions that would
be expected based on the results of other studies. In general, older
persons use more physician and home care services, have more hospital
and nursing home admissions, and have fewer dental care visits; and
those trends were exhibited by the population under study. Females in
the adult population use more health services than males, and this
relationship held here except for the use of hospital services. Differen-
tial use between males and females does, however, diminish with age
and, indeed, sex was not an important predictive variable in the latter
stages of the analysis.
Except for nursing home care, persons living alone used fewer
services. The explanation may be that persons who are healthier are
able to continue living alone, while those in poorer health are not able
to manage if they live by themselves, and thus live with others who are
able to provide assistance. As would be expected, the level of education
was positively correlated with use of dental care, but education was
negatively correlated with use of four of the six service categories. The
correlations of race with the utilization variables were inconsistent with
what would be expected. However, this may have been due to the small
number of blacks and other minorities in the sample.
The correlation of the ENABLING variables and the six depen-
dent variables would support the contention that financial barriers to
access of care have largely been removed, except for dental care. How-
ever, the relationships between income, occupation, education, and the
three types of insurance are fairly complex and should be examined
further. Those who reported having a regular physician used services
more, except for home care and ambulatory services. This may indi-
cate that entry into the health care system still depends, to some extent,
on having a personal physician to contact and that those who do not
have a physician turn to alternative sources of care.
Transportation was the only independent ENABLING variable
that was consistent in showing a statistically significant correlation with
the utilization variables. Those who said that transportation posed a
problem for them also reported using more physician services, more
ambulatory care, less dental care, more hospital and nursing home
care, and more home care services. It is likely that those who use more
services are sicker and thus find mobility and transportation more of a
problem than those who are healthier. The factor analysis supported
the idea that transportation problems could be considered a measure of
need. Despite the fact that transportation is reported as a problem, the
high service use by these respondents indicates that transportation does
not present an insurmountable barrier to obtaining care.
 Elderly and Health Care 379

It is worthwhile to look at the sample correlations from the per-

spective of the six utilization variables. One of the consistent trends
was that of the direction of the relationships of independent variables
with Dental Services-in the direction opposite that of their relation-
ships with Physician Services use. For example, use of dental services
was greater among younger persons, persons with higher education
and/or higher income, and persons who had relatively good functional
ability and self-perceived health status. Of the six services, all except
dentistry were used more by people having poor health status, as indi-
cated by each of the six independent variables. The dependent variable
for use of dental services showed an inverse relationship with each of
the NEED variables. This finding would be consistent with efforts to
improve access to care. Changes in funding and coverage have concen-
trated on medical services and have included, to varying degrees, hos-
pital, nursing home, and physician services, and ambulatory and home
care services. Dental services have been excluded until recently, and
this appears to be reflected in these 1974-1976 data. Furthermore,
dental care is often elective. Thus, despite the fact that many older
persons have trouble with their teeth (false or natural) and gums,
persons with other illnesses and limited resources would feel less need
to seek dental care than other types of care.
Multivariate analyses were used to clarify the findings of the
univariate analyses. The results suggest that caution should be used in
assessing the impact of one of the three constructs independent of the
others. For instance, when only one factor at a time was considered,
the results showed that high NEED was related to more utilization of
most services but that it caused less demand for dental care; that
PREDISPOSING factors were significantly related only to nursing
home admissions; and that the ENABLING factors were highly related
to dental use, but that the more able tended to use the other services
less. The three variables considered simultaneously, however, showed
that ENABLING factors were significantly and positively related to
physician utilization and that NEED was neither significantly nor
inversely related to dental use once the ENABLING factors were con-
trolled. Thus, the inverse relationships between the NEED and ENA-
BLING variables and the dependent variables, which were exhibited
when the constructs were examined separately, became clarified when
both types of variables were considered simultaneously.
When all of the independent variables were used, either separately
or as indexes, the R2 was generally low. While we have demonstrated
that the findings are important in the prediction of the use of groups of
people, the low R2 values demonstrate the large amount of variability
380 Health Services Research 19:3 (August 1984)
still unexplained by the Andersen model with respect to the use of
services by an individual. One possible reason for this lack of "fit" is that
we have operationalized the model using only the variables available -
which may or may not have been complete or optimal. Another possi-
bility is that there exist major explanatory dimensions to the utilization
of services which were not examined in this study.
As noted, Andersen's model has three types of components: indi-
vidual characteristics, system resources, and utilization measures. Due
to the limitations of the data set, we examined -only the individual
characteristics and utilization. The findings suggest that further analy-
sis involving the system component of the model is warranted.
A second consideration regarding the model is suggested. Ander-
sen's framework was developed during the 1960s when access to ser-
vices was one of the major issues of the health care delivery system.
Major changes in the health care system, particularly Medicare,
Medicaid, and the Older Americans Act, were designed to decrease
financial barriers to access of care and to encourage the development of
services to improve the availability of care. The elderly and poor,
populations with particular disadvantages in access to care, thus were
hypothesized to underutilize services. A model of utilization which
emphasized demographic and economic characteristics was appropri-
ate. Efforts to reduce discrimination in access focused on these groups.
To the extent that barriers to access based on age and/or income were
diminished between 1965 and 1975, and no longer differentiated the
population, a model using these as predictive variables would not be
successful in predicting utilization differences. Because recent changes
in public policies and funding potentially could reinstate barriers of
access, this model may be useful in explaining changes in utilization
that occur during the next few years,
The Andersen model may also be better in explaining service use
for a total population than for a specific segment of the population. By
selecting those who are old, have broad financial coverage, and have
other similar characteristics (such as the high likelihood of having a
chronic condition), the study may have reduced the variability that
otherwise would be available for attribution.
The relative importance of the three sets of variables is notewor-
thy. The PREDISPOSING and ENABLING variables are of minor
predictive value compared to the NEED variables. Although Table 12
demonstrates that even "weak" variables can predict important differ-
ences in utilization, these findings support the position that planning
future services based only on demographic and economic characteris-
tics would produce a less refined prediction of service use than would
estimating use based on the health status of the population. The utiliza-
 Elderly and Health Care 381

Table 12: The Importance of (Apparently) Low R2 Values

Utilization Measure Correlate R2 Mean Value
Hospitalization PHYSCOND .03 216/thousand
Physician visits EGFP .11 3.9
Dental visits Usual Occupation .05 .32
Estimate at 95% Confidence Interval
Utilization Measure Various Levels for Difference
Hospitalization Yes: 280/thou. (Yes-No) (100,200) adm/thou
No: 130/thou.
Physician visits Excel: 1.9 (poor-exc) (3.9,5.6) visits
Good: 3.5
Fair: 5.1
Poor: 6.6
Dental visits White col: .45 (white-blue) (.15,.27) visits
Blue col: .24

tion of services appears to be related to physical and functional status

far more than to economic status. Although this is well known to those
who have been working in the field of gerontology and long-term care,
it is not understood by many of the health care administrators and
planners who are only recently or peripherally involved in services for
the older population. Admittedly, health status is far harder to measure
and estimate than are demographic and economic status. However,
our findings suggest that the cost of collecting such data might be offset
by the improved predictive power of the model.
Those planning health services for older people would like to find
direct formulas, certainly, to make it easier to predict the amount of
services that will be demanded. The results of this study indicate that
the application of utilization models as currently formulated is not
simple; it does not produce clear-cut predictions of the use of services
by the population. Insight to the relative importance of certain factors
in explaining utilization of services on an aggregate basis may result,
however, from refinement of these models.

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382 Health Services Research 19:3 (August 1984)

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