The role of GIS for health utilization studies: literature review

Socioeconomic Barriers to Care for Pediatric Airways Utilizing Geographic Information Systems

OBJECTIVE

Geographic information systems (GIS) provide a unique set of tools to spatially analyze health care and identify patterns of health outcomes to help optimize delivery. Our goal is to create maps of pediatric tracheostomy patients using GIS to assess socioeconomic and other factors that impact postoperative care after discharge to home.

METHODS

A retrospective study was performed on patients (≤21 years old) who underwent tracheostomy at a tertiary care pediatric hospital from January 1, 2015 to December 31, 2020. Using GIS, we geocoded patient addresses and conducted spatial analyses of the relationship between patients and access to health care providers as well as vulnerable population factors including poverty, educational attainment, and single-parent households.

RESULTS

A total of 156 patients were included. Patients initially discharged to transitional care (108/156, 69.2%) had significantly higher likelihood of presenting to the ED regardless of socioeconomic status (OR: 2.28, 95% CI: 1.03-5.05; p = 0.042). There was no relationship between ED visit rate and median household income, poverty level, and percentage of uneducated adults (p = 0.490; p = 0.424; p = 0.752). Median distance to the tertiary care pediatric hospital was significantly longer for patients with no ED visit (median = 61.28 miles; SD = 50.90) compared with those with an ED visit (median = 37.75 miles; SD = 35.92) (p = 0.002).

CONCLUSION

The application of GIS could provide geo-localized data to better understand the healthcare barriers to access for children with tracheostomies. This study uniquely integrates medical record data with socioeconomic factors and social determinants of health.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1919-1925, 2024.

Impact of socioeconomic factors and health determinants on preterm birth in Brazil: a register-based study

BACKGROUND

More than 15 million children are born preterm annually. While preterm survival rates have increased in high-income countries. Low- and middle-income countries, like Brazil, continue to battle high neonatal mortality rates due to a lack of adequate postnatal care. Globally, neonatal mortality is higher for preterm infants compared to those born at term. Our study aims to map and analyze the spatial, socioeconomic, and health coverage determinants related to preterm birth in Brazil in order to understand how spatial variations in demographics and access to primary care may affect preterm birth occurrences.  METHODS: Using publicly available national-level data from the Brazilian health system for 2008-2017, we conducted an ecological study to visualize the spatial distributions of preterm birth along with socioeconomic status, the structure of health services, and primary care work process, each consisting of multiple variables reduced via principal component analysis. Regression models were created to determine predictive effects of numeric and spatial variation of these scores on preterm birth rates.

RESULTS

In Brazil, preterm birth rates increased from 2008-2017, with small and rural municipalities frequently exhibiting higher rates than urban areas. Scores in socioeconomic status and work process were significant predictors of preterm birth rates, without taking into account spatial adjustment, with more positive scores in socioeconomic status predicting higher preterm birth rates (coefficient 0.001145) and higher scores in work process predicting lower preterm birth rates (coefficient -0.002416). Geographically weighted regression showed socioeconomic status to be a more significant predictor in the North, with the work process indicators being most significant in the Northeast.

CONCLUSIONS

Results support that primary care work process indicators are more significant in estimating preterm birth rates than physical structures available for care. These results emphasize the importance of ensuring the presence of the minimum human resources needed, especially in the most deprived areas of Brazil. The association between social determinants of health and preterm birth rates raises questions regarding the importance of policies dedicated to foster equity in the accessibility of healthcare services, and improve income as protective proxies for preterm birth.

An informatics-driven intelligent system to improve healthcare accessibility for vulnerable populations

Broad disparities persist in access to healthcare and health outcomes in the United States, especially among vulnerable populations. An important step towards improving their healthcare access is to ensure "having access", or "accessibility". Drawing together the Behavioral Model of Health Services Use, social determinants of health (SDOH), and spatial healthcare accessibility literature, the research attempts to create an integrative accessibility measure to support the improvement of "having access" for vulnerable populations. A Vulnerable Population Healthcare Accessibility Framework (VPHAF) is proposed to systematically integrate vulnerable population characteristics, health behavior, customer satisfaction, and other SDOH factors to measure healthcare accessibility using advanced analytics. The qualitative and quantitative evaluation of VPHAF demonstrates that it enhances the existing spatial accessibility methods. An intelligent spatial decision support system (SDSS) instantiates the framework to support the decision making in improving healthcare accessibility for vulnerable populations in a regional healthcare plan. The system was evaluated by decision makers from a real-world organization as a useful tool with high usability. The intelligent SDSS enables the collection of SDOH data from multiple sources and uses analytics to measure healthcare accessibility focusing on characteristics of vulnerable populations. Policymakers and health plan providers can use the system to increase awareness of social risks and advocate for better policy decisions in creating equitable healthcare access and reducing health disparity.

Regional variation in travel to health services following transport-related major trauma

INTRODUCTION

Post-discharge healthcare needs are complex and persistent for people following major trauma. A number of geographic barriers to accessing healthcare exist, particularly for people in regional areas. The aim of this study was to explore regional variation in the distances travelled to access health services and identify patterns of health service use in the first three years following transport-related major trauma.

METHODS

This registry-based cohort study used linked data from the Victorian State Trauma Registry (VSTR) and the Transport Accident Commission (TAC). Victorians who sustained major trauma from a transport-related event between January 1 2006 and December 31 2016, with at least three years of follow-up TAC claims data were included in the study. Geospatial mapping of the median distance travelled to medical and allied health services was conducted for each Victorian Local Government Area.

RESULTS

In the first three years post-discharge, 4,964 people (75.6%) visited a general practitioner, 5058 (77.0%) saw other medical professionals, 2269 (34.6%) accessed mental health services, 2154 (32.8%) saw an occupational therapist and 4404 (67.0%) attended a physical therapy service. Geospatial mapping revealed that people in regional Local Government Area travelled further distances to access health services. Specific clustering of increased travel distances was observed in regional areas of the far west and north-east of Victoria. The number of people using services declined with each subsequent year beyond hospital discharge. However, the number of trips were consistent over time for those still engaged in services.

CONCLUSIONS

Distances travelled to access health services vary across geographic regions and may result in an increased travel burden for those in some regional Local Government Area. Understanding gaps in health services by geographic region can assist to improve service availability. Alternate service delivery methods, such as telehealth, may assist to reduce the associated burden of travel for those in regional areas.

Measuring hospital spatial accessibility using the enhanced two-step floating catchment area method to assess the impact of spatial accessibility to hospital and non-hospital care on the length of hospital stay

Background

Optimal healthcare access improves the health status and decreases health inequalities. Many studies demonstrated the importance of spatial access to healthcare facilities in health outcomes, particularly using the enhanced two-step floating catchment area (E2SFCA) method. The study objectives were to build a hospital facility access indicator at a fine geographic scale, and then to assess the impact of spatial accessibility to inpatient hospital and non-hospital care services on the length of hospital stay (LOS).

Methods

Data concerning older adults (≥75 years) living in the Nord administrative region of France were used. Hospital spatial accessibility was computed with the E2SFCA method, and the LOS score was calculated from the French national hospital activity and patient discharge database. The relationship between LOS and spatial accessibility to inpatient hospital care and to three non-hospital care types (general practitioners, physiotherapists, and home-visiting nurses) was analyzed with linear regression models.

Results

The mean number (standard deviation) of beds per 10,000 inhabitants was 19.0 (10.69) in Medical, Surgical and Obstetrics (MCO) facilities and 5.58 (2.19) in Postoperative and Rehabilitation Care (SSR) facilities, highlighting important variations within the region. Accessibility to hospital services was higher in large urban areas, despite the dense population and higher demand. In 2014, the mean LOS scores were 0.26 for MCO and 0.85 for SSR, but their geographical repartition was non-homogeneous. The linear regression analysis revealed a strong negative and significant association between LOS and non-hospital care accessibility.

Conclusions

This is the first study to measure spatial accessibility to inpatient hospital care in France using the E2SFCA method, and to investigate the relationship between healthcare utilization (LOS score) and spatial accessibility to inpatient hospital care facilities and three types of non-hospital care services. Our findings might help to make decisions about deploying additional beds and to identify the best locations for non-hospital care services. They might also contribute to improve access, and to ensure the best coordination and sustainability of inpatient and outpatient services, in order to better cover the population’s healthcare needs. International studies using multiple consensual indicators of healthcare outcomes and accessibility and sophisticated modeling methods are needed.

[Theoretical-methodological model based on Complex Network Theory for the analysis of the potential provision of health services]

The scope of this article is to present a theoretical-methodological model as the basis for the analysis of the potential provision of Brazilian public health services (SUS) using an approach based on complex network theory. The model sought to analyze the potential provision of health services through the relationship of Euclidean distance between census sectors and services offered by health facilities, as defined in the National Register of Health Establishments (CNES). Two types of metrics are proposed for the analysis of the relationship network: the average distance of health services to the census sectors and the importance of the health unit in the potential provision of each type of service based on the centrality and availability of this service. To demonstrate the application of the model, a network was built based in the Metropolitan Area of Brasilia, including the Federal District and 12 surrounding municipalities. The model was able to map and analyze CNES data with census sectors defined in the CENSUS, opening up the possibility of constructing new perspectives of analysis in the understanding of the potential distribution of health resources and services according to socioeconomic variables, as well as an important evidence-based management tool.

Assessing Health Resources Equipped with Hemodynamic Rooms in the Portuguese-Spanish Borderland: Cross-Border Cooperation Strategies as a Possible Solution

Portugal and Spain share one of the greatest European borderland areas. This fact has direct impacts on a large territory and consequently on the communities’ living in it. Still, even if the border areas represent an essential fraction of the territory, planning policies have not resulted in specific cooperation programs that could enable sharing general leisure and recreation assets and infrastructures and collaboration in critical domains—i.e., the case of the health sector. The present study aims to assess the territorial accessibility to the hemodynamic rooms by the potential population of the Spanish-Portuguese transition areas that may suffer an acute myocardial infarction. Contextually, this study employed a spatial interaction model based on the three-step floating catchment area method (method-3SFCA). By applying these methods, it was possible to develop a map of accessibility to health infrastructures equipped with hemodynamics rooms on both sides of the border that may answer the Spanish-Portuguese border populations’ needs. Besides, while granting valuable information for decision-makers regarding the need to develop new infrastructures to guarantee that even considering cross border cooperation, everyone gets access to a hemodynamics room within the critical intervention period.

Accessibility to primary health care in low-density regions. A case study: NUTS III - Baixo Alentejo - Portugal

This study diagnosed the situation regarding the physical accessibility of the resident population to primary health care, based on the characteristics of the population served, their spatial distribution in the territory, based on space-time analysis. Thus, bearing the different means of transport available and the specific features of a low-density territory, we considered several mobility profiles under analysis, and selected the Baixo Alentejo as the study area. In methodological terms, besides using the location of primary health facilities and their areas of influence, the use of the road network and its restrictions, we selected the use the new 1x1 km grid, recently implemented throughout the EU (European Union), instead of using the statistical units or administrative boundaries. Its advantages allow overcoming some of the issues of the usual base cartography. The final results can be divided into two groups: conclusions related to the methodologies used and conclusions related to the accessibility of primary health care equipment in the study area.

Efficiency of fine scale and spatial regression in modelling associations between healthcare service spatial accessibility and their utilization

BACKGROUND

Healthcare accessibility, a key public health issue, includes potential (spatial accessibility) and realized access (healthcare utilization) dimensions. Moreover, the assessment of healthcare service potential access and utilization should take into account the care provided by primary and secondary services. Previous studies on the relationship between healthcare spatial accessibility and utilization often used conventional statistical methods without addressing the scale effect and spatial processes. This study investigated the impact of spatial accessibility to primary and secondary healthcare services on length of hospital stay (LOS), and the efficiency of using a geospatial approach to model this relationship.

METHODS

This study focused on the ≥ 75-year-old population of the Nord administrative region of France. Inpatient hospital spatial accessibility was computed with the E2SFCA method, and then the LOS was calculated from the French national hospital activity and patient discharge database. Ordinary least squares (OLS), spatial autoregressive (SAR), and geographically weighted regression (GWR) were used to analyse the relationship between LOS and spatial accessibility to inpatient hospital care and to three primary care service types (general practitioners, physiotherapists, and home-visiting nurses). Each model performance was assessed with measures of goodness of fit. Spatial statistical methods to reduce or eliminate spatial autocorrelation in the residuals were also explored.

RESULTS

GWR performed best (highest R2 and lowest Akaike information criterion). Depending on global model (OLS and SAR), LOS was negatively associated with spatial accessibility to general practitioners and physiotherapists. GWR highlighted local patterns of spatial variation in LOS estimates. The distribution of areas in which LOS was positively or negatively associated with spatial accessibility varied when considering accessibility to general practitioners and physiotherapists.

CONCLUSIONS

Our findings suggest that spatial regressions could be useful for analysing the relationship between healthcare spatial accessibility and utilization. In our case study, hospitalization of elderly people was shorter in areas with better accessibility to general practitioners and physiotherapists. This may be related to the presence of effective community healthcare services. GWR performed better than LOS and SAR. The identification by GWR of how these relationships vary spatially could bring important information for public healthcare policies, hospital decision-making, and healthcare resource allocation.

Psychiatric readmission rates in a multi-level mental health care system - a descriptive population cohort study

BACKGROUND

Readmission rates are frequently used as a quality indicator for health care, yet their validity for evaluating quality is unclear. Published research on variables affecting readmission to psychiatric hospitals have been inconsistent. The Norwegian specialist mental health care system is characterized by a multi-level structure; hospitals providing specialized -largely unplanned care and district psychiatric centers (DPCs) providing generalized -more often planned care. In certain service systems, readmission may be an integral part of individual patients' treatment plan. The aim of the present study was to describe and examine the task division in a multi-level health care system. This we did through describing differences in patient population (age, sex, diagnosis, substance abuse comorbidity and length of stay) and admissions types (unplanned vs. planned) treated at different levels (hospital, DPC or both), and by examining whether readmission risk differ according to type and place of treatment of index-admission and travel-time to nearest hospital and DPC.

METHODS

In this population-based cohort study using administrative data we included all individuals aged 18 and older who were discharged from psychiatric inpatient care with an ICD-10 diagnosis F2-F6 ("functional mental disorders") in 2012. Selecting each individual's first discharge during 2012 as index gave N = 16,185 for analyses following exclusions. Analysis of readmission risk were done using Kaplan-Maier failure curves.

RESULTS

Overall, 15.1 and 47.7% of patients were readmitted within 30 and 365 days, respectively. Unplanned admission patients were more likely to be readmitted within 30 days than planned patients. Those transferred between hospital and DPC during index admission were more likely to be readmitted within 365 days, and to experience planned readmission. Patients with short travel time were more likely to have unplanned readmission, while patients with long travel time were more likely to have planned readmission.

CONCLUSIONS

DPCs and hospitals fill different purposes in the Norwegian health care system, which is reflected in different patient populations. Differences in short term readmission rates between hospitals and DPCs disappeared when type of admission (unplanned/planned) was considered. The results stress the importance of addressing differences in organisation and task distribution when comparing readmission rates between mental health systems.

Geographical inequalities in healthcare utilisation and the contribution of compositional factors: A multilevel analysis of 497 districts in Indonesia

Substantial inequalities in healthcare utilisation are reported in Indonesia. To develop appropriate health policies and interventions, we need to better understand geographical patterns in inequalities and any contributing factors. This study investigates geographical inequalities in healthcare utilisation across 497 districts in Indonesia and whether compositional factors - wealth, education, health insurance - contribute to such inequalities. Using data from a nationally representative Basic Health Research survey, from 2013 (N = 694,625), we applied multilevel logistic regressions, adjusted for need, to estimate associations of compositional factors with outpatient and inpatient care utilisation and to assess variability at province and district levels. We observed large variation of healthcare utilisation at district level and smaller variations at province level. Cities had higher utilisation rates than rural districts. Compositional factors contributed only modestly to geographical inequalities in healthcare utilisation. The effect of compositional factors on individual healthcare utilisation was stronger in rural areas as compared to cities and other areas with higher population densities. Unexplained district variation was substantial, comparable to that associated with health insurance. In policies to tackle inequalities in healthcare utilisation, addressing geographical factors such as service availability and infrastructures may be as important as improving compositional factors like health insurance.

The relationship between geographic location and outcomes following injury: A scoping review

INTRODUCTION

Globally, injury incidence and injury-fatality rates are higher in regional and remote areas. Recovery following serious injury is complex and requires a multi-disciplinary approach to management and community re-integration to optimise outcomes. A significant knowledge gap exists in understanding the regional variations in hospital and post-discharge outcomes following serious injury. The aim of this study was to review the evidence exploring the association between the geographic location, including both location of the event and place of residence, and outcomes following injury.

MATERIALS AND METHODS

A scoping review was used to investigate this topic and provide insight into geographic variation in outcomes following traumatic injury. Seven electronic databases and reference lists of relevant articles were searched from inception to October 2018. Studies were included if they measured injury-related mortality, outcomes associated with hospital admission, post-injury physical or psychological function and analysed these outcomes in relation to geographic location.

RESULTS

Of the 2,213 studies identified, 47 studies were included revealing three key groups of outcomes: mortality (n = 35), other in-hospital outcomes (n = 8); and recovery-focused outcomes (n = 12). A variety of measures were used to classify rurality across studies with inconsistent definitions of rurality/remoteness. Of the studies reporting injury-related mortality, findings suggest that there is a greater risk of fatality in rural areas overall and in the pre-hospital phase. For those patients that survived to hospital, the majority of studies included identified no difference in mortality between rural and urban patient groups. In the small number of studies that reported other in-hospital and recovery outcomes no consistent trends were identified.

CONCLUSION

Rural patients had a higher overall and pre-hospital mortality following injury. However, once admitted to hospital, there was no significant difference in mortality. Inconsistencies were noted across measures of rurality measures highlighting the need for more specific and consistent international classification methods. Given the paucity of data on the impact of geography on non-mortality outcomes, there is a clear need to develop a larger evidence base on regional variation in recovery following injury to inform the optimisation of post-discharge care services.

Spatial Accessibility and Social Inclusion: The Impact of Portugal's Last Health Reform

Health policies seek to promote access to health care and should provide appropriate geographical accessibility to each demographical functional group. The dispersal demand of health-care services and the provision for such services at fixed locations contribute to the growth of inequality in their access. Therefore, the optimal distribution of health facilities over the space/area can lead to accessibility improvements and to the mitigation of the social exclusion of the groups considered most vulnerable. Requiring for such, the use of planning practices joined with accessibility measures. However, the capacities of Geographic Information Systems in determining and evaluating spatial accessibility in health system planning have not yet been fully exploited. This paper focuses on health-care services planning based on accessibility measures grounded on the network analysis. The case study hinges on mainland Portugal. Different scenarios were developed to measure and compare impact on the population's accessibility. It distinguishes itself from other studies of accessibility measures by integrating network data in a spatial accessibility measure: the enhanced two-step floating catchment area. The convenient location for health-care facilities can increase the accessibility standards of the population and consequently reduce the economic and social costs incurred. Recently, the Portuguese government implemented a reform that aimed to improve, namely, the access and equity in meeting with the most urgent patients. It envisaged, in terms of equity, the allocation of 89 emergency network points that ensured more than 90% of the population be within 30 min from any one point in the network. Consequently, several emergency services were closed, namely, in rural areas. This reform highlighted the need to improve the quality of the emergency care, accessibility to each care facility, and equity in their access. Hence, accessibility measures become an efficient decision-making tool, despite its absence in effective practice planning. According to an application of this type of measure, it was possible to verify which levels of accessibility were decreased, including the most disadvantaged people, with a larger time of dislocation of 12 min between 2001 and 2011.

How can the spatial equity of health services be defined and measured? A systematic review of spatial equity definitions and methods

Background

Spatial equity analysis has been carried out in a variety of contexts and on a range of health services. However, there is no clear consensus on spatial equity definitions or measures. This review seeks to summarize spatial equity definitions and methods of analysis.

Methods

We systematically searched two electronic databases and six journals for papers providing a definition of spatial equity or performing a spatial equity analysis on health services. Studies were classified according to four definition themes: (1) distributional fairness; (2) needs-based distribution; (3) focus on outcomes or causes and (4) none provided.

Results

Seventy-five studies met our inclusion criteria. Sixty-one papers provided a definition of spatial equity, while a further 14 papers analysed the spatial equity of health services without providing a definition. Most authors used a needs-based definition of spatial equity, while the Gini coefficient was the most commonly used equity measure. However, analysis approaches varied according to the definition provided by each paper. Among the needs-based definitions, spatial autocorrelation was the most common spatial equity measure.

Conclusions

To our knowledge, this is the first systematic review summarizing spatial equity definitions and analysis methods. A lack of consensus on definitions and measures persists. The classification of measures according to definition themes makes this review a useful tool for planning and interpreting spatial equity investigations. Future research should examine the impact different measures of accessibility and need have on the results of spatial equity research.

Evaluating an MFI Community Health Worker Program: How microfinance group networks influence intervention outreach and impact

BACKGROUND

Community Health Workers (CHWs) are considered to be a cost-effective and inclusive solution to address the persistent health workforce shortage in many low and middle-income countries. In recent years, microfinance institutions (MFIs) got increasingly engaged in providing health services delivered by CHWs. Despite their growing importance, little is known about the impacts and implementation barriers of these mostly small-scale initiatives. This paper evaluates an MFI-led CHW program in the Philippines and studies the role of microfinance group networks in influencing program outreach and impact. The intervention aims at disseminating information in poor communities, improving health monitoring through increased check-ups and raising social support.

METHODS

Clustered randomized controlled trial in 70 communities in the greater area of Metro Manila, the Philippines. The main data was collected in a baseline and follow-up survey and is complemented with extensive sociometric network and geographical data. The main outcome variable is a composite health index based on 10 indicators. The role of the health worker's embeddedness and connectedness in the community for program success is tested using tools of social network analysis.

RESULTS

The intervention led to a 3.8% (95% confidence interval (CI) = 1.3, 6.4) improvement in the composite health outcome. Effects across indicators are mixed and mainly driven by changes in immediate health monitoring behavior: The probability for routine examinations increased in the treatment group by 10.6% (95% CI = 3.2, 18.1), for regular blood pressure checks by 9.6% (95% CI = 3.3, 15.9), and for having access to a health care provider by 7.2% (95% CI = 0.93, 13.5). No statistical effects on general knowledge and social support are observable. Social networks are a key driver of program outreach and impact. Close friends and acquaintances of health workers used and benefited substantially more from the program than more distant ties.

CONCLUSIONS

Despite the promising immediate behavioral impacts, it remains questionable to what extent such small-scale MFI initiatives can bring transformative and sustainable changes without external support. Microfinance group networks played an important role for the success of the health intervention and further research is needed to better understand how these affect the health care utilization decisions of the clients.

Health care access and glycemic control in youth and young adults with type 1 and type 2 diabetes in South Carolina

Affordability and geographic accessibility are key health care access characteristics. We used data from 481 youth and young adults (YYA) with diabetes (389 type 1, 92 type 2) to understand the association between health care access and glycemic control as measured by HbA1c values. In multivariate models, YYA with state or federal health insurance had HbA1c percentage values 0.68 higher (P = 0.0025) than the privately insured, and those without insurance 1.34 higher (P < 0.0001). Not having a routine diabetes care provider was associated with a 0.51 higher HbA1c (P = 0.048) compared to having specialist care, but HbA1c did not differ significantly (P = 0.069) between primary vs specialty care. Distance to utilized provider was not associated with HbA1c among YYA with a provider (P = 0.11). These findings underscore the central role of health insurance and indicate a need to better understand the root causes of poorer glycemic control in YYA with state/federal insurance.

Using floating catchment area (FCA) metrics to predict health care utilization patterns

BACKGROUND

Floating Catchment Area (FCA) metrics provide a comprehensive measure of potential spatial accessibility to health care services and are often used to identify geographic disparities in health care access. An unexplored aspect of FCA metrics is whether they can be useful in predicting where people actually seek care. This research addresses this question by examining the utility of FCA metrics for predicting patient utilization patterns, the flows of patients from their residences to facilities.

METHODS

Using more than one million inpatient hospital visits in Michigan, we calculated expected utilization patterns from Zip Codes to hospitals using four FCA metrics and two traditional metrics (simple distance and a Huff model) and compared them to observed utilization patterns. Because all of the accessibility metrics rely on the specification of a distance decay function and its associated parameters, we conducted a sensitivity analysis to evaluate their effects on prediction accuracy.

RESULTS

We found that the Three Step FCA (3SFCA) and Modified Two Step FCA (M2SFCA) were the most effective metrics for predicting utilization patterns, correctly predicting the destination hospital for nearly 74% of hospital visits in Michigan. These two metrics were also the least sensitive to changes to the distance decay functions and parameter settings.

CONCLUSIONS

Overall, this research demonstrates that FCA metrics can provide reasonable predictions of patient utilization patterns and FCA utilization models could be considered as a substitute when utilization pattern data are unavailable.

Beyond bus fare: deconstructing prenatal care travel among low-income urban mothers through a mix methods GIS study

OBJECTIVE

Guided by critical theory, this study illustrates the value of interpretative mapping to deconstruct bus travel to publicly funded prenatal care in a city marked by health and social inequities.

METHODS

This mixed methods study used GIS maps based on 61,305 births to study the known barrier of transportation to prenatal care among urban mothers most at risk for preterm birth.

RESULTS

Among 350 census tracts, 36 census tracts had preterm rates between 25 -36.9%. Modeling travel time for the case vignette for routine prenatal care took 21 visits to different geographically located facilities. This burden increased to 32 visits if the case vignette was high-risk.

CONCLUSIONS

Interpretative GIS mapping is an important tool to ground truth spatially linked data into real world meanings. Promoting optimal health requires innovative and feasible approaches that take into consideration daily maternal functioning as pregnant mothers care for their children and themselves.

The equity of access to primary dental care in São Paulo, Brazil: A geospatial analysis

OBJECTIVES

Brazil is one of the largest countries in the world, in terms of geography and population. Most Brazilians reside in the south and south-eastern regions, with notable numbers in the regions' megacities, such as São Paulo city. Healthcare provision in such a complex environment is difficult. Thus, a clear understanding of the distribution - or rather, the maldistribution - of these services is fundamental for optimising the allocation of human and financial resources to areas of greatest privation. The present study aimed to determine the distribution of primary dental clinics in São Paulo city.

METHODS

A total of 4,101 primary dental clinics in São Paulo city were identified and geocoded. Clinic locations were integrated with the city's 19,128 constituent census tracts - each containing sociodemographic data for the 11,252,204 residents - using Geographic Information Systems (GIS).

RESULTS

Approximately two-thirds (64.8%) of the population resided within 0.5 km of a primary dental clinic, and a further 23.9% were within 1 km. Populations more than 1 km out were typically characterised as sociodemographically disadvantaged. Primary dental clinics were also more sparsely distributed in the city's peripheral census tracts than central census tracts.

CONCLUSION

Primary dental clinics are maldistributed in São Paulo city, with disadvantaged populations having less spatial access than their advantaged counterparts.

Spatially balanced provision of health equipment: a cross-sectional study oriented to the identification of challenges to access promotion

BACKGROUND

Access to health services is in part defined by the spatial distribution of healthcare equipment. To ensure equity in the provision of health services, it is important to examine availability across different health care providers taking into account population demand. Given the importance of the equitable provision of health equipment, we evaluate its spatial distribution in Brazil.

METHODS

This study is classified as cross-sectional with an ecological design. We evaluate Brazilian data on distance to available health equipment considering: dialysis machines (385), magnetic resonance imaging (MRI) (257), hospital beds (3675) and bone densitometers (429). We define two distance thresholds (50 km and 200 km) from a municipality to the center of services provision. The balance between infrastructure capacity and potential demand was evaluated to identify a lack or surplus of health services.

RESULTS

The distribution of dialysis equipment and bone densitometers is not balanced across Brazilian states, and unmet demand is high. With respect to MRIs, the large capacity of this equipment results in a large excess of supply. However, this characteristic alone cannot account for excesses of supply of over 700%, as is the case of the Federal District when the range is limited to 50 km. At the same time, four states in the Northeastern region of Brazil show a net excess of demand. Some regions do not meet the standard amount of supply defined by Brazilian Ministry of Health. The quantity and distribution of hospital beds are not sufficient to provide full coverage to the population.

CONCLUSION

Our main focus was to evaluate the network of the provision of health equipment in Brazil, considering both private and public sectors conjointly. We take into account two main aspects of a spatially balanced health system: the regional availability of health equipment and the geographic distance between its demand and supply at the municipality level. Some regions do not meet the minimum requirement defined by the Brazilian Ministry of Health regarding the supply of health services.

A cancer geography paradox? Poorer cancer outcomes with longer travelling times to healthcare facilities despite prompter diagnosis and treatment: a data-linkage study

BACKGROUND

Rurality and distance from cancer treatment centres have been shown to negatively impact cancer outcomes, but the mechanisms remain obscure.

METHODS

We analysed the impact of travel time to key healthcare facilities and mainland/island residency on the cancer diagnostic pathway (treatment within 62 days of referral, and within 31 days of diagnosis) and 1-year mortality using a data-linkage study with 12 339 patients.

RESULTS

After controlling for important confounders, mainland patients with more than 60 min of travelling time to their cancer treatment centre ((OR 1.42; 95% CI 1.25-1.61) and island dwellers (OR 1.32; 95% CI 1.09-1.59) were more likely to commence cancer treatment within 62 days of general practitioner (GP) referral and within 31 days of their cancer diagnosis compared with those living within 15 min. Island-dweller patients were more likely to have their diagnosis and treatment started on the same or next day (OR 1.72; 95% CI 1.31-2.25). Increased travelling time to a cancer treatment centre was associated with increased mortality to 1 year (30-59 min (HR 1.21; 95% CI 1.05-1.41), >60 min (HR 1.18; 95% CI 1.03-1.36), island dweller (HR 1.17; 95% CI 0.97-1.41).

CONCLUSIONS

Island dwelling and greater mainland travel burden was associated with more rapid cancer diagnosis and treatment following GP referral even after adjustment for advanced disease; however, these patients also experienced a survival disadvantage compared with those living nearer. Cancer services may need to be better configured to suit the different needs of dispersed populations.

Mapping Patterns and Trends in the Spatial Availability of Alcohol Using Low-Level Geographic Data: A Case Study in England 2003-2013

Much literature examines the relationship between the spatial availability of alcohol and alcohol-related harm. This study aims to address an important gap in this evidence by using detailed outlet data to examine recent temporal trends in the sociodemographic distribution of spatial availability for different types of alcohol outlet in England. Descriptive analysis of measures of alcohol outlet density and proximity using extremely high resolution market research data stratified by outlet type and quintiles of area-level deprivation from 2003, 2007, 2010 and 2013 was undertaken and hierarchical linear growth models fitted to explore the significance of socioeconomic differences. We find that overall availability of alcohol changed very little from 2003 to 2013 (density +1.6%), but this conceals conflicting trends by outlet type and area-level deprivation. Mean on-trade density has decreased substantially (-2.2 outlets within 1 km (Inter-Quartile Range (IQR) -3-0), although access to restaurants has increased (+1.0 outlets (IQR 0-1)), while off-trade access has risen substantially (+2.4 outlets (IQR 0-3)). Availability is highest in the most deprived areas (p < 0.0001) although these areas have also seen the greatest falls in on-trade outlet availability (p < 0.0001). This study underlines the importance of using detailed, low-level geographic data to understand patterns and trends in the spatial availability of alcohol. There are significant variations in these trends by outlet type and deprivation level which may have important implications for health inequalities and public health policy.

How to allocate limited healthcare resources: Lessons from the introduction of antiretroviral therapy in rural Mozambique

Proper allocation of limited healthcare resources is a challenging task for policymakers in developing countries. Allocation of and access to these resources typically varies based on how need is defined, thus determining how individuals access and acquire healthcare. Using the introduction of antiretroviral therapy in southern Mozambique as an example, we examine alternative definitions of need for rural populations and how they might impact the allocation of this vital health service. Our results show that how need is defined matters when allocating limited healthcare resources and the use of need-based metrics can help ensure more optimal distribution of services.

North Carolina physician-based preventive oral health services improve access and use among young Medicaid enrollees

To combat disparities in oral health and access to dental care among infants and toddlers, most state Medicaid programs now reimburse physician-based preventive oral health services such as fluoride varnish applications. We used geospatial data to examine the distribution of dental and medical Medicaid providers of pediatric oral health services throughout North Carolina to determine if these services have improved access to care for Medicaid enrollees younger than age three. We then used claims data to examine the association between distance from these practices and use of dental services for a cohort of approximately 1,000 young children. Among one hundred counties, four counties had no physician-based preventive oral health services, and nine counties had no dental practice. While children who lived farther from the nearest dental practice were less likely to make dental visits, distance from physician-based preventive oral health services did not predict utilization. For young Medicaid enrollees, oral health services provided in medical offices can improve access and increase utilization.

Variation in geographic access to chemotherapy by definitions of providers and service locations: a population-based observational study

Background

An aging population, with its associated rise in cancer incidence and strain on the oncology workforce, will continue to motivate patients, healthcare providers and policy makers to better understand the existing and growing challenges of access to chemotherapy. Administrative data, and SEER-Medicare data in particular, have been used to assess patterns of healthcare utilization because of its rich information regarding patients, their treatments, and their providers. To create measures of geographic access to chemotherapy, patients and oncologists must first be identified. Others have noted that identifying chemotherapy providers from Medicare claims is not always straightforward, as providers may report multiple or incorrect specialties and/or practice in multiple locations. Although previous studies have found that specialty codes alone fail to identify all oncologists, none have assessed whether various methods of identifying chemotherapy providers and their locations affect estimates of geographic access to care.

Methods

SEER-Medicare data was used to identify patients, physicians, and chemotherapy use in this population-based observational study. We compared two measures of geographic access to chemotherapy, local area density and distance to nearest provider, across two definitions of chemotherapy provider (identified by specialty codes or billing codes) and two definitions of chemotherapy service location (where chemotherapy services were proven to be or possibly available) using descriptive statistics. Access measures were mapped for three representative registries.

Results

In our sample, 57.2 % of physicians who submitted chemotherapy claims reported a specialty of hematology/oncology or medical oncology. These physicians were associated with 91.0 % of the chemotherapy claims. When providers were identified through billing codes instead of specialty codes, an additional 50.0 % of beneficiaries (from 23.8 % to 35.7 %) resided in the same ZIP code as a chemotherapy provider. Beneficiaries were also 1.3 times closer to a provider, in terms of driving time. Our access measures did not differ significantly across definitions of service location.

Conclusions

Measures of geographic access to care were sensitive to definitions of chemotherapy providers; far more providers were identified through billing codes than specialty codes. They were not sensitive to definitions of service locations, as providers, regardless of how they are identified, generally provided chemotherapy at each of their practice locations.

Estimating demand and unmet need for allogeneic hematopoietic cell transplantation in the United States using geographic information systems

PURPOSE

Allogeneic hematopoietic cell transplantation (HCT) is an increasingly used therapy for many patients with hematologic malignancies and other marrow failure or immune system disorders. The purpose of this study was to quantify and visualize both the demand and unmet need for HCT.

METHODS

HCT use for 2012 was described using the Center for International Blood and Marrow Transplant Research registry. Potential demand for HCT was calculated using 2012 SEER data and published literature for HCT-treatable conditions. Point locations of transplant centers were geocoded using geographic information system (GIS) software; Thiessen polygons were created to establish adult (age 20 to 74 years) and pediatric (age 0 to 19 years) market areas. Market-area population estimates were calculated using 2012 population estimates by age aggregated by census block.

RESULTS

US market areas for HCTs were identified separately for transplant centers treating adult (n = 62) and pediatric patients (n = 52). Overall HCT demand among adults was 16,096, with an unmet need for HCTs of 10,276 patients. For pediatric patients, the total demand was 4,561, with an unmet need of 3,213 potential recipients. Evaluation of adult and pediatric market areas indicated that the largest unmet needs tended to be in areas with large populations.

CONCLUSION

Market-area maps and statistics developed using GIS will help communicate the unmet need for HCT, inform policy, and assist transplant centers in planning for the anticipated growth in HCT use.

Multi-modal two-step floating catchment area analysis of primary health care accessibility

Two-step floating catchment area (2SFCA) techniques are popular for measuring potential geographical accessibility to health care services. This paper proposes methodological enhancements to increase the sophistication of the 2SFCA methodology by incorporating both public and private transport modes using dedicated network datasets. The proposed model yields separate accessibility scores for each modal group at each demand point to better reflect the differential accessibility levels experienced by each cohort. An empirical study of primary health care facilities in South Wales, UK, is used to illustrate the approach. Outcomes suggest the bus-riding cohort of each census tract experience much lower accessibility levels than those estimated by an undifferentiated (car-only) model. Car drivers' accessibility may also be misrepresented in an undifferentiated model because they potentially profit from the lower demand placed upon service provision points by bus riders. The ability to specify independent catchment sizes for each cohort in the multi-modal model allows aspects of preparedness to travel to be investigated.

Do the classification of areas and distance matter to the assessment results of achieving the treatment targets among type 2 diabetes patients?

Background

Type 2 diabetes is a major health concern all over the world. The prevention of diabetes is important but so is well-balanced diabetes care. Diabetes care can be influenced by individual and neighborhood socio-economic factors and geographical accessibility to health care services. The aim of the study is to find out whether two different area classifications of urban and rural areas give different area-level results of achieving the targets of control and treatment among type 2 diabetes patients exemplified by a Finnish region. The study exploits geo-referenced patient data from a regional primary health care patient database combined with postal code area-level socio-economic variables, digital road data and two grid based classifications of areas: an urban–rural dichotomy and a classification with seven area types.

Methods

The achievement of control and treatment targets were assessed using the patient’s individual laboratory data among 9606 type 2 diabetes patients. It was assessed whether hemoglobin A1c (HbA1c) was controlled and whether the recommended level of HbA1c was achieved in patients by different area classes and as a function of distance. Chi square test and logistic regression analysis were used for testing.

Results

The study reveals that area-level inequalities exist in the care of type 2 diabetes in a detailed 7-class area classification but if the simple dichotomy of urban and rural is applied differences vanish. The patient’s gender and age, area-level education and the area class they belonged to were associated with achievements of control and treatment targets. Longer distance to health care services was not a barrier to good achievements of control or treatment targets.

Conclusions

A more detailed grid-based area classification is better for showing spatial differences in the care of type 2 diabetes patients. Inequalities exist but it would be misleading to state that the differences are simply due to urban or rural location or due to distance. From a planning point of view findings suggest that detailed geo-coded patient information could be utilized more in resourcing and targeting the health care services to find the area-level needs of care and to improve the cost-efficient allocation of resources.

Application of spatial analysis technology to the planning of access to oral health care for at-risk populations in Australian capital cities

Australians are one of the healthiest populations in the world but there is strong evidence that health inequalities exist. Australia has 23.1 million people spread very unevenly over ~20 million square kilometres. This study aimed to apply spatial analysis tools to measure the spatial distribution of fixed adult public dental clinics in the eight metropolitan capital cities of Australia. All population data for metropolitan areas of the eight capital cities were integrated with socioeconomic data and health-service locations, using Geographic Information Systems, and then analysed. The adult population was divided into three subgroups according to age, consisting of 15-year-olds and over (n = 7.2 million), retirees 65 years and over (n = 1.2 million), and the elderly, who were 85 years and over (n = 0.15 million). It was evident that the States fell into two groups; Tasmania, Northern Territory, Australian Capital Territory and Western Australia in one cluster, and Victoria, New South Wales, Queensland and South Australia in the other. In the first group, the average proportion of the population of low socioeconomic status living in metropolitan areas within 2.5 km of a government dental clinic is 13%, while for the other cluster, it is 42%. The clustering remains true at 5 km from the clinics. The first cluster finds that almost half (46%) of the poorest 30% of the population live within 5 km of a government dental clinic. The other cluster of States finds nearly double that proportion (86%). The results from this study indicated that access distances to government dental services differ substantially in metropolitan areas of the major Australian capital cities.

Surgical patients travel longer distances than non-surgical patients to receive care at a rural hospital in Mozambique

BACKGROUND

Surgical care is increasingly recognised as an important component of global health delivery. However, there are still major gaps in knowledge related to access to surgical care in low-income countries. In this study, we compare distances travelled by surgical patients with patients seeking other medical services at a first-level hospital in rural Mozambique.

METHODS

Data were collected on all inpatients at Hospital Rural de Chókwè in rural Mozambique between 20 June 2012 and 3 August 2012. Euclidean distances travelled by surgical versus non-surgical patients using coordinates of each patient's city of residence were compared. Data were analysed using ArcGIS 10 and STATA.

RESULTS

In total, 500 patients were included. Almost one-half (47.6%) lived in the city where the hospital is based. By hospital ward, the majority (62.0%) of maternity patients came from within the hospital's city compared with only 35.2% of surgical patients. The average distance travelled was longest for surgical patients (42 km) compared with an average of 17 km for patients on all other wards.

CONCLUSIONS

Patients seeking surgical care at this first-level hospital travel farther than patients seeking other services. While other patients may have access to at community clinics, surgical patients depend more heavily on the services available at first-level hospitals.

Efficiency of points of dispensing for influenza A(H1N1)pdm09 vaccination, Los Angeles County, California, USA, 2009

During October 23-December 8, 2009, the Los Angeles County Department of Public Health used points of dispensing (PODs) to improve access to and increase the number of vaccinations against influenza A(H1N1)pdm09. We assessed the efficiency of these units and access to vaccines among ethnic groups. An average of 251 persons per hour (SE 65) were vaccinated at the PODs; a 10% increase in use of live-attenuated monovalent vaccines reduced that rate by 23 persons per hour (SE 7). Vaccination rates were highest for Asians (257/10,000 persons), followed by Hispanics (114/10,000), whites (75/100,000), and African Americans (37/10,000). Average distance traveled to a POD was highest for whites (6.6 miles; SD 6.5) and lowest for Hispanics (4.7 miles; SD ±5.3). Placing PODs in areas of high population density could be an effective strategy to reach large numbers of persons for mass vaccination, but additional PODs may be needed to improve coverage for specific populations.

Efficiency of points of dispensing for influenza A(H1N1)pdm09 vaccination, Los Angeles County, California, USA, 2009

During October 23–December 8, 2009, the Los Angeles County Department of Public Health used points of dispensing (PODs) to improve access to and increase the number of vaccinations against influenza A(H1N1)pdm09. We assessed the efficiency of these units and access to vaccines among ethnic groups. An average of 251 persons per hour (SE 65) were vaccinated at the PODs; a 10% increase in use of live-attenuated monovalent vaccines reduced that rate by 23 persons per hour (SE 7). Vaccination rates were highest for Asians (257/10,000 persons), followed by Hispanics (114/10,000), whites (75/100,000), and African Americans (37/10,000). Average distance traveled to a POD was highest for whites (6.6 miles; SD 6.5) and lowest for Hispanics (4.7 miles; SD ±5.3). Placing PODs in areas of high population density could be an effective strategy to reach large numbers of persons for mass vaccination, but additional PODs may be needed to improve coverage for specific populations.

Analyzing spatial clustering and the spatiotemporal nature and trends of HIV/AIDS prevalence using GIS: the case of Malawi, 1994-2010

BACKGROUND

Although local spatiotemporal analysis can improve understanding of geographic variation of the HIV epidemic, its drivers, and the search for targeted interventions, it is limited in sub-Saharan Africa. Despite recent declines, Malawi's estimated 10.0% HIV prevalence (2011) remained among the highest globally. Using data on pregnant women in Malawi, this study 1) examines spatiotemporal trends in HIV prevalence 1994-2010, and 2) for 2010, identifies and maps the spatial variation/clustering of factors associated with HIV prevalence at district level.

METHODS

Inverse distance weighting was used within ArcGIS Geographic Information Systems (GIS) software to generate continuous surfaces of HIV prevalence from point data (1994, 1996, 1999, 2001, 2003, 2005, 2007, and 2010) obtained from surveillance antenatal clinics. From the surfaces prevalence estimates were extracted at district level and the results mapped nationally. Spatial dependency (autocorrelation) and clustering of HIV prevalence were also analyzed. Correlation and multiple regression analyses were used to identify factors associated with HIV prevalence for 2010 and their spatial variation/clustering mapped and compared to HIV clustering.

RESULTS

Analysis revealed wide spatial variation in HIV prevalence at regional, urban/rural, district and sub-district levels. However, prevalence was spatially leveling out within and across 'sub-epidemics' while declining significantly after 1999. Prevalence exhibited statistically significant spatial dependence nationally following initial (1995-1999) localized, patchy low/high patterns as the epidemic spread rapidly. Locally, HIV "hotspots" clustered among eleven southern districts/cities while a "coldspot" captured configurations of six central region districts. Preliminary multiple regression of 2010 HIV prevalence produced a model with four significant explanatory factors (adjusted R2 = 0.688): mean distance to main roads, mean travel time to nearest transport, percentage that had taken an HIV test ever, and percentage attaining a senior primary education. Spatial clustering linked some factors to particular subsets of high HIV-prevalence districts.

CONCLUSIONS

Spatial analysis enhanced understanding of local spatiotemporal variation in HIV prevalence, possible underlying factors, and potential for differentiated spatial targeting of interventions. Findings suggest that intervention strategies should also emphasize improved access to health/HIV services, basic education, and syphilis management, particularly in rural hotspot districts, as further research is done on drivers at finer scale.

Spatial and social inequities in HIV testing utilization in the context of rapid scale-up of HIV/AIDS services in rural Mozambique

The massive scale-up of HIV counseling, testing, and treatment services in resource-limited sub-Saharan settings with high HIV prevalence has significant implications for the course of the HIV/AIDS epidemic. It also offers important broader policy lessons for improving access to critical health services. Applying GIS-based methods and multilevel regression analysis to unique longitudinal three-wave survey data from rural Mozambique, this study investigates the impact of a rapid expansion of HIV-related services on access to and utilization of HIV testing. The results illustrate the declining importance of spatial barriers to utilization of HIV testing services as these services expanded. In addition, the expansion of HIV-related services decreased the spatial variability of HIV testing among the survey respondents. At the same time, some important non-spatial variation, such as that in educational level, persisted despite the expansion of services. These results illustrate the process and consequences of health service diffusion.

Spatial accessibility of drug treatment facilities and the effects on locus of control, drug use, and service use among heroin-injecting Mexican American men

BACKGROUND

This study explores the spatial accessibility of outpatient drug treatment facilities and the potential relationship with drug use-related outcomes among Mexican American heroin users.

METHODS

Secondary data on 219 current and former heroin-injecting Mexican American men aged 45 and older were drawn from a research study in Houston, Texas. We used geographic information systems (GIS) to derive two spatial accessibility measures: distance from one's place of residence to the closest drug treatment facility (in minutes); and the number of facilities within a 10-minute driving distance from one's place of residence. Exploratory logistic regression analyses examined the association between the spatial accessibility of drug treatment facilities and several drug use-related outcomes: internal locus of control (LOC); perceived chances and worries of injecting in the next six months; treatment utilization; and location of last heroin purchase.

RESULTS

Participants with greater spatial access to treatment programs were more likely to report a higher chance of injecting in the near future. However, while current heroin users were more worried about injecting in the next six months, greater spatial access to treatment programs seemed to have a buffering effect. Finally, those who lived closer to a treatment programs were more likely to have last purchased heroin inside the neighborhood versus outside the neighborhood. Spatial accessibility was not associated with internal LOC or treatment utilization.

CONCLUSION

The findings showed that the presence of outpatient treatment facilities-particularly services in Spanish-may influence perceived risk of future heroin use and purchasing behaviors among Mexican American men. Implications for future spatially-informed drug use research and the planning of culturally and linguistically responsive drug treatment programs are discussed.

A geographical perspective on access to sexual and reproductive health care for women in rural Africa

Utilization of sexual and reproductive health (SRH) services can significantly impact health outcomes, such as pregnancy and birth, prenatal and neonatal mortality, maternal morbidity and mortality, and vertical transmission of infectious diseases like HIV/AIDS. It has long been recognized that access to SRH services is essential to positive health outcomes, especially in rural areas of developing countries, where long distances as well as poor transportation conditions, can be potential barriers to health care acquisition. Improving accessibility of health services for target populations is therefore critical for specialized healthcare programs. Thus, understanding and evaluation of current access to health care is crucial. Combining spatial information using geographical information system (GIS) with population survey data, this study details a gravity model-based method to measure and evaluate access to SRH services in rural Mozambique, and analyzes potential geographic access to such services, using family planning as an example. Access is found to be a significant factor in reported behavior, superior to traditional distance-based indicators. Spatial disparities in geographic access among different population groups also appear to exist, likely affecting overall program success.

A systematic review of the application of spatial analysis in pharmacoepidemiologic research

PURPOSE

Although current reviews of the use of spatial analysis in general epidemiologic research illustrate an important and well-established role in exploring and predicting health, its application has not been reviewed in the subspecialty field of pharmacoepidemiology.

METHODS

We systematically reviewed the scientific literature to assess to what extent spatial analysis has been applied in pharmacoepidemiologic research and explored its potential added value.

RESULTS

A systematic search in PubMed and Embase/MEDLINE yielded 823 potentially relevant articles; 45 articles met our criteria for review. The studies were reviewed on study objective, applied spatial methods and units of analysis, and author-reported added value of the geographic approach used. Of the 45 included studies, 34 (76%) reported a geographic research objective. Comparative spatial methods were most often used (n = 25; 56%). Eleven studies used spatial statistics (32%); cluster analysis (n = 5) and aggregate data analysis (n = 4) being most common. Mapping was done in 15 studies (33%). The most common added value reported was to aid the planning of health policies and interventions (n = 24; 53%). A minority of pharmacoepidemiologic studies used a geographic approach and the applied methods were less advanced compared with the broader field of epidemiology.

CONCLUSIONS

Further advancements are needed to incorporate currently available spatial techniques to impact health care planning.

Using geographical information systems to explore disparities in preterm birth rates among foreign-born and U.S.-born Black mothers

OBJECTIVE

To examine spatial patterns of neighborhood contextual factors of stress with preterm birth (PTB) and nativity (foreign-born and U.S.-born) among Black mothers.

DESIGN

Descriptive geographic-spatial research.

SETTING & PARTICIPANTS

Births to Philadelphia residents during 2003-2005 in the context of Philadelphia residential neighborhoods (N = 350) were studied.

METHODS

All data were aggregated to neighborhood levels (census tracts). Maps were created to assess geographic-spatial patterns. A geographic information system (GIS) database was created that imported geo-coded data on births, crime (assaults with guns and domestic abuse), poverty, race, and nativity (foreign-born vs. U.S.-born).

RESULTS

Clear visual patterns of "bad" neighborhoods emerged and were significantly associated with higher prevalence of PTB for foreign-born Black and U.S.-born Black mothers (p < .0001).

CONCLUSIONS

This study demonstrated how GIS visually clarified important spatial patterns of adverse living conditions and PTB prevalence. Nurses can use GIS to better understand living environments of mothers and their families and to target interventions in geographical areas with the greatest service needs. Further research on individual and contextual factors is warranted to address the observed health disparities among the heterogeneous groups of foreign-born Black mothers. Despite limitations of aggregate data, it is clear that where mothers live matters. This has important implications for nursing practice and policy.

Measuring geographic access to health care: raster and network-based methods

Background

Inequalities in geographic access to health care result from the configuration of facilities, population distribution, and the transportation infrastructure. In recent accessibility studies, the traditional distance measure (Euclidean) has been replaced with more plausible measures such as travel distance or time. Both network and raster-based methods are often utilized for estimating travel time in a Geographic Information System. Therefore, exploring the differences in the underlying data models and associated methods and their impact on geographic accessibility estimates is warranted.

Methods

We examine the assumptions present in population-based travel time models. Conceptual and practical differences between raster and network data models are reviewed, along with methodological implications for service area estimates. Our case study investigates Limited Access Areas defined by Michigan’s Certificate of Need (CON) Program. Geographic accessibility is calculated by identifying the number of people residing more than 30 minutes from an acute care hospital. Both network and raster-based methods are implemented and their results are compared. We also examine sensitivity to changes in travel speed settings and population assignment.

Results

In both methods, the areas identified as having limited accessibility were similar in their location, configuration, and shape. However, the number of people identified as having limited accessibility varied substantially between methods. Over all permutations, the raster-based method identified more area and people with limited accessibility. The raster-based method was more sensitive to travel speed settings, while the network-based method was more sensitive to the specific population assignment method employed in Michigan.

Conclusions

Differences between the underlying data models help to explain the variation in results between raster and network-based methods. Considering that the choice of data model/method may substantially alter the outcomes of a geographic accessibility analysis, we advise researchers to use caution in model selection. For policy, we recommend that Michigan adopt the network-based method or reevaluate the travel speed assignment rule in the raster-based method. Additionally, we recommend that the state revisit the population assignment method.

Geographic influences on sexual and reproductive health service utilization in rural Mozambique

The HIV/AIDS epidemic remains a major public health issue across the globe, and it is of particular concern in sub-Saharan Africa. Utilization of sexual and reproductive health (SRH) services can significantly impact HIV prevention, transmission, and treatment. SRH service utilization may be determined by individual characteristics, such as education and economic status, but also by the location and accessibility of health care facilities. Using population-based survey data, this study applies exploratory spatial analysis techniques to examine spatial patterns of SRH service utilization among rural married women in southern Mozambique. Clustering among those using services is found as are spatial associations, indicating significant spatial variability in the utilization of health services. The findings provide valuable insights for current and future health care program planning and configuration.

Using GIS and perceived distance to understand the unequal geographies of healthcare in lower-income urban neighbourhoods

Geographers play important roles in public health research, particularly in understanding healthcare accessibility, utilisation, and individual healthcare experiences. Most accessibility studies have benefited from the increased sophistication of geographic information systems (GIS). Some studies have been enhanced with semi-structured in-depth interviews to understand individual experiences of people as they access healthcare. However, few accessibility studies have explicitly utilised individual in-depth interview data in the construction of new GIS accessibility measures. Using mixed methods including GIS analysis and individual data from semi-structured in-depth interviews, we offer satisfaction-adjusted distance as a new way of conceptualising accessibility in GIS. Based on fieldwork in a predominantly lower-income community in Columbus, Ohio (USA), we find many residents felt neighbourhood healthcare facilities offered low-quality care, which suggested an added perceived distance as they attempt to access high-quality healthcare facilities. The satisfaction-adjusted distance measure accounts for the perceived distance some residents feel as they search for high-quality healthcare in lower-income urban neighbourhoods. In moving beyond conventional GIS and re-conceptualising accessibility in this way, we offer a more realistic portrayal of the issues lower-income urban residents face as they attempt to access high-quality healthcare facilities. The work has theoretical implications for conceptualising healthcare accessibility, advances the mixed-methodologies literature, and argues for a more equitable distribution of high-quality healthcare in urban neighbourhoods.

A spatial analysis of variations in health access: linking geography, socio-economic status and access perceptions

Background

This paper analyses the relationship between public perceptions of access to general practitioners (GPs) surgeries and hospitals against health status, car ownership and geographic distance. In so doing it explores the different dimensions associated with facility access and accessibility.

Methods

Data on difficulties experienced in accessing health services, respondent health status and car ownership were collected through an attitudes survey. Road distances to the nearest service were calculated for each respondent using a GIS. Difficulty was related to geographic distance, health status and car ownership using logistic generalized linear models. A Geographically Weighted Regression (GWR) was used to explore the spatial non-stationarity in the results.

Results

Respondent long term illness, reported bad health and non-car ownership were found to be significant predictors of difficulty in accessing GPs and hospitals. Geographic distance was not a significant predictor of difficulty in accessing hospitals but was for GPs. GWR identified the spatial (local) variation in these global relationships indicating locations where the predictive strength of the independent variables was higher or lower than the global trend. The impacts of bad health and non-car ownership on the difficulties experienced in accessing health services varied spatially across the study area, whilst the impacts of geographic distance did not.

Conclusions

Difficulty in accessing different health facilities was found to be significantly related to health status and car ownership, whilst the impact of geographic distance depends on the service in question. GWR showed how these relationships were varied across the study area. This study demonstrates that the notion of access is a multi-dimensional concept, whose composition varies with location, according to the facility being considered and the health and socio-economic status of the individual concerned.

Investigation of disparities in geographic accessibility to emergency stroke and myocardial infarction care in East tennessee using geographic information systems and network analysis

PURPOSE

Stroke and myocardial infarction (MI) require timely geographic accessibility to emergency care. Historically, studies used straight line distances as measures of geographic accessibility. Recently, travel time has been recognized as a better indicator of accessibility because travel impedances can be considered. This study used finer grained transportation data and network analysis to investigate neighborhood disparities in travel time to emergency stroke and MI care.

METHODS

Travel times to stroke and cardiac centers were computed using network analysis, while considering distance, speed limit, road connectivity, and turn impedances. Neighborhoods within 30, 60, or 90 minutes travel were identified. Travel time by air ambulance was calculated and adjusted for flying speed and some delays.

RESULTS

Approximately 8% and 15% of the study population did not have timely geographic accessibility to emergency stroke and MI care, respectively. Populations with poor access were located in rural areas. The entire study population had timely access by air ambulance.

CONCLUSIONS

This study identified disparities in geographic accessibility to emergency stroke and MI care in East Tennessee. Use of air ambulance or telemedicine could play a vital role in addressing these disparities. This information is important for evidence-based health planning and resource allocation.

How far?: Using geographical information systems (GIS) to examine maternity care access for expectant mothers in a rural state

Various factors have made rural access to maternity care a significant problem for rural women. The geographic distance between a mother's county of residence and the county in which she gave birth was examined in a rural state. Analyzing North Dakota county-level data using geographic information system (GIS) software, women from over half of the state's counties, making up nearly 18% of all births, were found to be over 40 miles to the hospital in which they gave birth. These findings suggest that rural women may experience significant geographic barriers as they receive health services in the prenatal, delivery, and postpartum periods of their pregnancy. We highlight the value of GIS, particularly geovisualization power, and note models of care that may be effective for rural women.