title: Area-level determinants of specialty care utilization in France: a multilevel analysis.
abstract: OBJECTIVE
  We investigated the effects of the density of specialists and of the area-level percentage of highly educated individuals on the odds of consulting a specialist, and examined whether these variables could explain the observed urban/rural contrast in utilization of specialty care.
  
  
  METHODS
  The study sample, representative of the French population aged 18-75 years in 1999, comprised 12,435 individuals.
  
  
  METHODS
  Multilevel logistic models allowed us to investigate predictors of the odds of consulting a specialist occasionally, regularly and frequently over the previous 12 months.
  
  
  RESULTS
  We observed a modest but significant clustering within areas of the utilization of specialty care, with higher levels of clustering for behaviours representing heavy consumption of care. After adjustment for individual factors, the odds of consulting a specialist were higher in larger cities compared with rural areas, but most of this effect was attributable to other area-level variables. These area-level effects were different in magnitude and nature among males and females. Among males, the odds of consulting a specialist increased with the area-level density of specialists. Among females, such an effect was not significant, but the odds of consulting a specialist increased with the area-level percentage of highly educated individuals.
  
  
  CONCLUSIONS
  Further investigation is required to better understand the processes operating at the area level that were shown to affect healthcare utilization in a different way for males and females. Policies may be needed to address problems of geographical access to specialty care, as well as situations of overuse of specialty care without regular recourse to primary care.
authors.affiliation: Research Unit in Epidemiology and Information Sciences, National Institute of Health and Medical Research (INSERM U444), Paris, France. chaix@u444.jussieu.fr
authors.forename: B
authors.initials: B
authors.lastname: Chaix
authors.forename: P-Y
authors.initials: PY
authors.lastname: Boëlle
authors.forename: P
authors.initials: P
authors.lastname: Guilbert
authors.forename: P
authors.initials: P
authors.lastname: Chauvin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002391:Catchment Area, Health / Q000706:statistics & numerical data*; D016000:Cluster Analysis; D005260:Female; D005602:France / Q000453:epidemiology; D005843:Geography; D019538:Health Care Surveys; D006297:Health Services Accessibility; D006280:Health Workforce; D006801:Humans; D008297:Male; D008511:Medicine / Q000706:statistics & numerical data*; D008875:Middle Aged; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012423:Rural Health; D012959:Socioeconomic Factors; D013038:Specialization; D014504:Urban Health