Relationships between road-distance to primary care facilities and ischemic heart disease and stroke mortality in Hokkaido, Japan: A Bayesian hierarchical approach to ecological count data

Association between travel distance and face-to-face consultations with general practitioners before an incident acute myocardial infarction: a nationwide register-based spatial epidemiological study

OBJECTIVES

This study examined the association between travel distance to the general practitioner's (GP) office and no face-to-face GP consultation within 1 year before an incident acute myocardial infarction (AMI).

DESIGN

A prospective cohort study using multilevel spatial logistic regression analysis of nationwide register data.

SETTING

Nationwide study including contacts to GPs in Denmark prior to an incident AMI in 2005-2017.

PARTICIPANTS

121 232 adults (≥30 years) with incident AMI were included in the study.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome was odds of not having a face-to-face GP consultation within 1 year before an incident AMI.

RESULTS

In total, 13 108 (10.8%) of the 121 232 individuals with incident AMI had no face-to-face consultation with the GP within 1 year before the AMI. Population density modified the association between travel distance and no face-to-face GP consultation. Increased odds of no face-to-face GP consultation was observed for medium (25th-75th percentile/1123-5449 m) and long (>75th percentile/5449 m) compared with short travel distance (<25th percentile/1123 m) among individuals living in small cities (OR (95% credible intervals) of 1.19 (1.10 to 1.29) and 1.19 (1.06 to 1.33), respectively) and rural areas (1.46 (1.26 to 1.68) and 1.48 (1.29 to 1.68), respectively). No association was observed for individuals living in large cities and the capital.

CONCLUSIONS

Travel distance above approximately 1 km was significantly associated with no face-to-face GP consultation before an incident AMI among individuals living in small cities and rural areas. The structure of the healthcare system should consider the importance of geographical distance between citizens and the GP in remote areas.

A Systematic Review of Areal Units and Adjacency Used in Bayesian Spatial and Spatio-Temporal Conditional Autoregressive Models in Health Research

Advancements in Bayesian spatial and spatio-temporal modelling have been observed in recent years. Despite this, there are unresolved issues about the choice of appropriate spatial unit and adjacency matrix in disease mapping. There is limited systematic review evidence on this topic. This review aimed to address these problems. We searched seven databases to find published articles on this topic. A modified quality assessment tool was used to assess the quality of studies. A total of 52 studies were included, of which 26 (50.0%) were on infectious diseases, 10 (19.2%) on chronic diseases, 8 (15.5%) on maternal and child health, and 8 (15.5%) on other health-related outcomes. Only 6 studies reported the reasons for using the specified spatial unit, 8 (15.3%) studies conducted sensitivity analysis for prior selection, and 39 (75%) of the studies used Queen contiguity adjacency. This review highlights existing variation and limitations in the specification of Bayesian spatial and spatio-temporal models used in health research. We found that majority of the studies failed to report the rationale for the choice of spatial units, perform sensitivity analyses on the priors, or evaluate the choice of neighbourhood adjacency, all of which can potentially affect findings in their studies.

Spatial-temporal analysis of cerebral infarction mortality in Hokkaido, Japan: an ecological study using a conditional autoregressive model

BACKGROUND

Accessibility to stroke treatments is a challenge that depends on the place of residence. However, recent advances in medical technology have improved health outcomes. Nevertheless, the geographic heterogeneity of medical resources may increase regional disparities. Therefore, evaluating spatial and temporal influences of the medical system on regional outcomes and advanced treatment of cerebral infarction are important from a health policy perspective. This spatial and temporal study aims to identify factors associated with mortality and to clarify regional disparities in cerebral infarction mortality at municipality level.

METHODS

This ecological study used public data between 2010 and 2020 from municipalities in Hokkaido, Japan. We applied spatial and temporal condition autoregression analysis in a Bayesian setting, with inference based on the Markov chain Monte Carlo simulation. The response variable was the number of deaths due to cerebral infarction (ICD-10 code: I63). The explanatory variables were healthcare accessibility and socioeconomic status.

RESULTS

The large number of emergency hospitals per 10,000 people (relative risk (RR) = 0.906, credible interval (Cr) = 0.861 to 0.954) was associated with low mortality. On the other hand, the large number of general hospitals per 10,000 people (RR = 1.123, Cr = 1.068 to 1.178) and longer distance to primary stroke centers (RR = 1.064, Cr = 1.014 to 1.110) were associated with high mortality. The standardized mortality ratio decreased from 2010 to 2020 in Hokkaido by approximately 44%. Regional disparity in mortality remained at the same level from 2010 to 2015, after which it narrowed by approximately 5% to 2020. After mapping, we identified municipalities with high mortality rates that emerged in Hokkaido's central and northeastern parts.

CONCLUSION

Cerebral infarction mortality rates and the disparity in Hokkaido improved during the study period (2010-2020). This study emphasized that healthcare accessibility through places such as emergency hospitals and primary stroke centers was important in determining cerebral infarction mortality at the municipality level. In addition, this study identified municipalities with high mortality rates that require healthcare policy changes. The impact of socioeconomic factors on stroke is a global challenge, and improving access to healthcare may reduce disparities in outcomes.

Doctors' contributions to primary care in outpatient clinics in depopulated areas within Hokkaido

Objective: To examine how doctors who work in outpatient clinics in depopulated areas in Hokkaido contribute to the provision of primary care to residents.

Methods: The study adopted a qualitative research design. Six doctors, all of whom were men and in charge of medical clinics located in depopulated areas in Hokkaido, participated in a semi-structured interview. The interviews were recorded using a digital voice recorder. The data were transcribed and classified into codes, subcategories, and categories, and analyzed.

Results: A qualitative analysis yielded the following five superordinate categories: (1) clinical praxis in accordance with residents’ lifestyles and life stages; (2) innovative care provision based on residents’ conditions; (3) provision of routine care in partnership with other healthcare providers and associated stakeholders; (4) beliefs and feelings of pride associated with working as doctors in clinics in depopulated areas; and (5) difficulties in guaranteeing reliable and continuous operation of clinics in depopulated areas.

Conclusion: This study successfully identified the specific contributions of doctors working in outpatient clinics in depopulated areas to primary care, as well as the related challenges that they face. Moving forward, researchers should continue to examine how the issues faced by clinics in depopulated areas can be addressed using regional medical care plans.

Job Stress Factors Affect Workplace Resignation and Burnout among Japanese Rural Physicians

Shortage of healthcare workers is a global problem. It is important to clarify factors, including job stress, that influence workplace resignation and factors that cause burnout among rural physicians. The study was designed as a cross-sectional questionnaire survey. We sent questionnaires to town or village hospitals and clinics (n = 1,898) in Hokkaido, Tohoku, Shikoku, and Kyushu and Okinawa. The number of participants was 509. Of these 7.7% were female and 21.6% were < 50 years. Internal or general medicine physicians were asked about personal and job factors, job stress based on the demand-control-support model, intention to resign from current position, and burnout evaluated using the Maslach Burnout Inventory-General Survey. Overall, 10.4% of the participants intended to resign, and 21.8% was defined as burnout positive. In the multivariate logistic regression analysis, dissatisfaction with income (OR, 3.63; 95% CI, 1.63-8.10), having one's hometown in another town or village in the same prefecture (OR, 3.53; 95% CI, 1.18-10.62) were significantly related to intention to resign, while high job control (OR, 0.72; 95% CI, 0.58-0.88) had a significantly protective effect. In the multivariate analysis, high job demand (OR, 1.48; 95% CI, 1.28-1.72) was significantly related to burnout, and high job control (OR, 0.66; 95% CI, 0.55-0.78) and high support from co-workers (OR 0.88, 95% CI, 0.78-1.00) had a significantly protective effect. Improving job stress factors, especially job control, and taking into consideration physicians' hometown and income may be important factors to prevent resignation from a current position and burnout among Japanese rural physicians.

Relationships between road-distance to primary care facilities and ischemic heart disease and stroke mortality in Hokkaido, Japan: A Bayesian hierarchical approach to ecological count data

Objective

Poor access to a primary care physician may lead to poor control of risk factors for disease. This study investigated whether geographic access to a primary care physician was related to ischemic heart disease and stroke mortality.

Methods

Road‐distances from the centroids of the basic unit blocks of the 2010 Japanese Census to the nearest primary care facilities in Hokkaido, northern Japan, were measured using geographic information system (GIS) software. Next, block population‐weighted mean road‐distances to primary care facilities in all municipalities were calculated. The numbers of deaths from ischemic heart disease and stroke were obtained from the Vital Statistics Bureau. A Bayesian spatial conditional autoregressive (CAR) model was used to analyze relative risk (RR) by road‐distance with the numbers of physicians in the municipality included as a covariate.

Results

Relative risk (per 1 kilometer increased) of death from ischemic heart disease to road‐distance to the nearest primary care facility was not significantly higher in men (1.108: 95% credible interval [CI] 0.999‐1.037) and women (1.023: 95% CI 1.000‐1.046). However, RR of death from stroke was significantly higher in men (1.019: 95% CI 1.005‐1.032) and women (1.019: 95% CI 1.006‐1.033).

Conclusion

Longer road‐distance to a primary care facility may increase the risk of stroke mortality.