More on the geographical distribution of physicians

Location dynamics of general practitioners in France

Background

For several years now, the socio-political context in France has widened the territorial divide between metropolitan France and peripheral France. Access to healthcare is part of this divide, which harms small and medium-sized towns as well as rural fringes. This article focuses on these geographic dynamics in access to healthcare, with a focus on self-employed general practitioners (GPs), who are essential links in the care pathway as referring physicians.

Methods

This paper uses data from French public statistics from 2007 to 2017 to build spatial panels and to highlight the territorial factors that explain the dynamics of the locations of GPs.

Results

Over the period under review, the density of GPs has decreased and territorial disparity has increased. There is no trend towards a worsening of this isolation of either the periphery or deprived cantons with regard to the density of GPs in these areas. However, we note a clear trend towards the grouping together of different types of care within cantons, leading to a tendency towards the polarization of the healthcare supply in the territories of mainland France, which implies another type of geographical difficulty.

Conclusion

The increase in territorial disparities in accessibility to GPs does not really seem to correspond to the classical divides in France, but rather raises the issue of intra-metropolis and intra-periphery disparities.

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There is a worsening of access to general practitioners between 2007 and 2017.

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Territorial inequalities in access to general practitioners have also increased.

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Spatial dynamics are studied with spatial panels.

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There is a tendency for doctors to group together in the same cantons.

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GPs seem particularly attracted by the availability of services.

Finding flaws in the spatial distribution of health workforce and its influential factors: An empirical analysis based on Chinese provincial panel data, 2010-2019

Background

The maldistributions of the health workforce showed great inconsistency when singly measured by population quantity or geographic area in China. Meanwhile, earlier studies mainly employed traditional econometric approaches to investigate determinants for the health workforce, which ignored spillover effects of influential factors on neighboring regions. Therefore, we aimed to analyze health workforce allocation in China from demographic and geographic perspectives simultaneously and then explore the spatial pattern and determinants for health workforce allocation taking account of the spillover effect.

Methods

The health resource density index (HRDI) equals the geometric mean of health resources per 1,000 persons and per square kilometer. First, the HRDI of licensed physicians (HRDI_P) and registered nurses (HRDI_N) was calculated for descriptive analysis. Then, global and local Moran's I indices were employed to explore the spatial features and aggregation clusters of the health workforce. Finally, four types of independent variables were selected: supportive resources (bed density and government health expenditure), healthcare need (proportion of the elderly population), socioeconomic factors (urbanization rate and GDP per capita), and sociocultural factors (education expenditure per pupil and park green area per capita), and then the spatial panel econometric model was used to assess direct associations and intra-region spillover effects between independent variables and HRDI_P and HRDI_N.

Results

Global Moran's I index of HRDI_P and HRDI_N increased from 0.2136 (P = 0.0070) to 0.2316 (P = 0.0050), and from 0.1645 (P = 0.0120) to 0.2022 (P = 0.0080), respectively. Local Moran's I suggested spatial aggregation clusters of HRDI_P and HRDI_N. For HRDI_P, bed density, government health expenditure, and GDP had significantly positive associations with local HRDI_P, while the proportion of the elderly population and education expenditure showed opposite spillover effects. More precisely, a 1% increase in the proportion of the elderly population would lead to a 0.4098% increase in HRDI_P of neighboring provinces, while a 1% increase in education expenditure leads to a 0.2688% decline in neighboring HRDI_P. For HRDI_N, the urbanization rate, bed density, and government health expenditure exerted significantly positive impacted local HRDI_N. In addition, the spillover effect was more evident in the urbanization rate, with a 1% increase in the urbanization rate relating to 0.9080% growth of HRDI_N of surrounding provinces. Negative spillover effects of education expenditure, government health expenditure, and elderly proportion were observed in neighboring HRDI_N.

Conclusion

There were substantial spatial disparities in health workforce distribution in China; moreover, the health workforce showed positive spatial agglomeration with a strengthening tendency in the last decade. In addition, supportive resources, healthcare needs, and socioeconomic and sociocultural factors would affect the health labor configuration not only in a given province but also in its nearby provinces.

The role of financial factors in the mobility and location choices of General Practitioners in Australia

BACKGROUND

The geographic distribution of health workers is a pervasive policy concern. Many governments are responding by introducing financial incentives to attract health care workers to locate in areas that are underserved. However, clear evidence of the effectiveness of such financial incentives is lacking.

METHODS

This paper examines General Practitioners' (GPs) relocation choices in Australia and proposes a dynamic location choice model accounting for both source and destination factors associated with a choice to relocate, thereby accounting for push and pull factors associated with job separation. The model is used to simulate financial incentive policies and assess potential for such policies to redistribute GPs. This paper examines the role of financial factors in relocating established GPs into neighbourhoods with relatively low socioeconomic status. The paper uses a discrete choice model and panel data on GPs' actual changes in location from one year to the next.

RESULTS

This paper finds that established GPs are not very mobile, even when a financial incentive is offered. Policy simulation predicts that 93.2% of GPs would remain at their current practice and that an additional 0.8% would be retained or would relocate in a low-socioeconomic status (SES) neighbourhood in response to a hypothetical financial incentive of a 10% increase in the earnings of all metropolitan GPs practising in low-SES neighbourhoods.

CONCLUSION

With current evidence on the effectiveness of redistribution programmes limited to newly entering GPs, the policy simulations in this paper provide an insight into the potential effectiveness of financial incentives as a redistribution policy targeting the entire GP population. Overall, the results suggest that financial considerations are part of many factors influencing the location choice of GPs. For instance, GP practice ownership played almost as important a role in mobility as earnings.

Market structure and competition in the healthcare industry : Results from a transition economy

The present paper provides first empirical evidence on the relationship between market size and the number of firms in the healthcare industry for a transition economy. We estimate market-size thresholds required to support different numbers of suppliers (firms) for three occupations in the healthcare industry in a large number of distinct geographic markets in Slovakia, taking into account the spatial interaction between local markets. The empirical analysis is carried out for three time periods (1995, 2001 and 2010) which characterise different stages of the transition process. Our results suggest that the relationship between market size and the number of firms differs both across industries and across periods. In particular, we find that pharmacies, as the only completely liberalised market in our dataset, experience the largest change in competitive behaviour during the transition process. Furthermore, we find evidence for correlation in entry decisions across administrative borders, suggesting that future market analysis should aim to capture these regional effects.

What influences national and foreign physicians' geographic distribution? An analysis of medical doctors' residence location in Portugal

BACKGROUND

The debate over physicians' geographical distribution has attracted the attention of the economic and public health literature over the last forty years. Nonetheless, it is still to date unclear what influences physicians' location, and whether foreign physicians contribute to fill the geographical gaps left by national doctors in any given country. The present research sets out to investigate the current distribution of national and international physicians in Portugal, with the objective to understand its determinants and provide an evidence base for policy-makers to identify policies to influence it.

METHODS

A cross-sectional study of physicians currently registered in Portugal was conducted to describe the population and explore the association of physician residence patterns with relevant personal and municipality characteristics. Data from the Portuguese Medical Council on physicians' residence and characteristics were analysed, as well as data from the National Institute of Statistics on municipalities' population, living standards and health care network. Descriptive statistics, chi-square tests, negative binomial and logistic regression modelling were applied to determine: (a) municipality characteristics predicting Portuguese and International physicians' geographical distribution, and; (b) doctors' characteristics that could increase the odds of residing outside the country's metropolitan areas.

RESULTS

There were 39,473 physicians in Portugal in 2008, 51.1% of whom male, and 40.2% between 41 and 55 years of age. They were predominantly Portuguese (90.5%), with Spanish, Brazilian and African nationalities also represented. Population, Population's Purchasing Power, Nurses per capita and Municipality Development Index (MDI) were the municipality characteristics displaying the strongest association with national physicians' location. For foreign physicians, the MDI was not statistically significant, while municipalities' foreign population applying for residence appeared to be an additional positive factor in their location decisions. In general, being foreigner and male resulted to be the physician characteristics increasing the odds of residing outside the metropolitan areas. However, among the internationals, older doctors were more likely to reside outside metropolitan areas. Being Spanish or Brazilian (but not of African origin) was found to increase the odds of being based outside the Lisbon and Oporto metropolitan areas.

CONCLUSIONS

The present study showed the relevance of studying one country's physician population to understand the factors driving national and international doctors' location decisions. A more nuanced understanding of national and foreign doctors' location appears to be needed to design more effective policies to reduce the imbalance of medical services across geographical areas.

Vocation and avocation: leisure activities correlate with professional engagement, but not burnout, in a cross-sectional survey of UK doctors

BACKGROUND

Sir William Osler suggested in 1899 that avocations (leisure activities) in doctors are related to an increased sense of vocation (professional engagement) and a decreased level of burnout. This study evaluated those claims in a large group of doctors practicing in the UK while taking into account a wide range of background variables.

METHODS

A follow-up questionnaire was sent to 4,457 UK-qualified doctors who had been included in four previous studies of medical school selection and training, beginning in 1980, 1985, 1990 and 1989/1991. A total of 2,845 (63.8%) doctors returned the questionnaire. Questions particularly asked about work engagement, satisfaction with medicine as a career, and personal achievement (Vocation/engagement), stress, emotional exhaustion, and depersonalization (BurnedOut), and 29 different leisure activities (Avocation/Leisure), as well as questions on personality, empathy, work experience, and demography.

RESULTS

Doctors reporting more Avocation/Leisure activities tended to be women, to have older children, to be less surface-rational, more extravert, more open to experience, less agreeable, and to fantasize more. Doctors who were more BurnedOut tended to be men, to be more sleep-deprived, to report a greater workload and less choice and independence in their work, to have higher neuroticism, lower extraversion and lower agreeableness scores, and to have lower self-esteem. In contrast, doctors with a greater sense of Vocation/engagement, tended to see more patients, to have greater choice and independence at work, to have a deep approach to work, to have a more supportive-receptive work environment, to be more extravert and more conscientious, and to report greater self-esteem.Avocation/Leisure activities correlated significantly with Vocation/engagement, even after taking into account 25 background variables describing demography, work, and personality, whereas BurnedOut showed no significant correlation with Avocation/Leisure activities. Popular Culture and High Culture did not differ in their influence on Vocation/engagement, although there was a suggestion that Depersonalization was correlated with more interest in Popular Culture and less interest in High Culture.

CONCLUSION

In this cross-sectional study there is evidence, even after taking into account a wide range of individual difference measures, that doctors with greater Avocation/Leisure activities also have a greater sense of Vocation/Engagement. In contrast, being BurnedOut did not relate to Avocation/Leisure activities (but did relate to many other measures). Osler was probably correct in recommending to doctors that, 'While medicine is to be your vocation, or calling, see to it that you also have an avocation'.

Disparities in geographic access to pediatric subspecialty care

PURPOSE

To identify correlates of geographic access to pediatric medical subspecialists in the United States and identify characteristics of populations at risk for poor geographic access.

METHODS

Geographic access was operationalized as distance to care. Using data from the American Board of Pediatrics and the Claritas' Pop-Facts Database, the straight-line distance between each zip code in the United States and the nearest subspecialist was calculated for each pediatric subspecialty using zip code centroids. Using 16 specialty-specific, random-effects multiple regression models, zip code characteristics associated with being farther from a subspecialty provider were identified.

RESULTS

Under-18 population, metropolitan status, and presence of a nearby teaching facility were associated with shorter distances to care across pediatric subspecialties. The proportion of the population below the federal poverty level was positively associated with greater distances to care. Zip codes in the Mountain and West North Central regions, likewise, were significantly farther from pediatric subspecialists, even when statistically controlling for other factors.

CONCLUSIONS

Pediatric populations at risk for poor geographic access to pediatric subspecialty care include those who reside in zip codes with high concentrations of poverty, in rural and small metropolitan areas, and in the Mountain and West North Central regions. The extent to which these distances create barriers to receipt of care is not established.

Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce

Access to good-quality health services is crucial for the improvement of many health outcomes, such as those targeted by the Millennium Development Goals (MDGs) adopted by the international community in 2000. The health-related MDGs cannot be achieved if vulnerable populations do not have access to skilled personnel and to other necessary inputs. This paper focuses on the geographical dimension of access and on one of its critical determinants: the availability of qualified personnel. The objective of this paper is to offer a better understanding of the determinants of geographical imbalances in the distribution of health personnel, and to identify and assess the strategies developed to correct them. It reviews the recent literature on determinants, barriers and the effects of strategies that attempted to correct geographical imbalances, with a focus on empirical studies from developing and developed countries. An analysis of determinants of success and failures of strategies implemented, and a summary of lessons learnt, is included.

Should the gap be filled between guidelines and actual practice for management of low back pain in primary care? The Quebec experience

STUDY DESIGN

A prospective cohort study.

OBJECTIVES

To describe health services utilization for low back pain in the province of Quebec, Canada, and to compare it with North American guidelines.

SUMMARY OF BACKGROUND DATA

The Quebec Task Force and the Agency for Health Care Planning and Research (United States) published guidelines for the management of low back pain in 1987 and 1994, respectively.

METHODS

A cohort of 2147 adults with low back pain identified at the Quebec Worker's Compensation Board were selected randomly and observed over 2 years' time for their health care utilization profile.

RESULTS

During the study period, 57.8% of the workers still under active care 7 weeks after their back injury had not yet been referred to a specialist. Specialized imaging techniques were obtained by 4.5% of the patients, with a delay of 7 weeks or more in 66% of them. Surgery was performed on 1.6% of the patients. The presence of an initial specific diagnosis and proximity to a university hospital significantly increased utilization rate and reduced the delays.

CONCLUSION

Health services utilization for back pain in Quebec was equal or lower to what currently is practiced elsewhere, but access to specialists was not meeting the current recommendations. This would represent a 12% net increase in new specialist contacts and a quicker access in 39% who saw a specialist. Before such an effort can be considered, health care planners will need a better definition of the role of the specialist consultation in the guidelines and scientific evidence specifically addressing their benefit in primary care, especially in the absence of a specific diagnosis.

Deviation from the carrying capacity for physicians and growth rate of physician supply: the Taiwan case

This study applies the theory of carrying capacity to examine the effects of market forces on the location pattern of physicians in Taiwan between 1974 and 1982. The data for the analysis were collected from governmental publications. The township was selected as the geographic unit of analysis. By using a regression model of physician supply, this study developed a proxy for physician carrying capacity and a deviation indicator to classify townships as attractive or unattractive. The results of this study indicate that: (1) within attractive townships, the greater the deviation from physician carrying capacity, the faster the growth rate of the physician-population ratio; (2) the overall pattern of the growth rate is quite similar across different sizes of townships; and (3) due to a loss of population, unattractive townships do not necessarily have the lowest growth rates of the physician-population, unattractive they gain few physicians. This study thus concludes that market forces are powerful in determining the physician distribution.

Using Gini-style indices to evaluate the spatial patterns of health practitioners: theoretical considerations and an application based on Alberta data

The paper analyzes how Gini-style indices are optimally used in the evaluation of economic spatial models designed to predict where health care practitioners are likely to locate under competitive market conditions. At a conceptual level, the analysis establishes that Gini-style indices can be brought to bear on economic models, only if the ordering of geographic areas required to give Gini-coefficient values internal technical coherence also has meaning in terms of the conceptual predictions of the modelling. This, in turn, implies that Gini-indices are most likely to prove useful for fairly aggregated forms of economic analysis, involving relatively few and large geographic divisions. At an applied level, the analysis establishes that one particular geographic distribution of health practitioners is empirically dominant, and that is the distribution which involves the lowest practitioner:population ratio in rural areas, and the highest ratio in large urban areas, with the ratio for small urban areas in between. The empirical evidence also suggests that the spatial practitioner distributions are highly stable for most kinds of health personnel, making it problematic whether these distributions can be changed through normal types of public policy interventions.

The geographical distribution of psychiatrists in Canada: unmet needs and remedial strategies

Many efforts are underway to rationalize the process of manpower planning in psychiatry. A wide variation in the geographic distribution of psychiatrists remains. A multidimensional assessment of the needs of a population is recommended, based on the epidemiology of mental disorders, professional and institutional needs, consumer estimates, and the requirements of subgroups. Counting the number of vacant positions for psychiatrists can be misleading. Professional norms for the optimal access of a population to psychiatric services and standards for the quantity and/or quality of services provided need to be developed. Potential outcome measures are suggested, along with a three-tiered system of estimating geographic needs. Deterrent factors to an optimal geographic distribution of most professionals are reviewed, along with factors specific to our residency training programs. In the short term, the benefits and limitations of recruiting foreign-trained psychiatrists are compared with those of recruiting Canadian specialists. Complementary long term strategies include the provision of financial incentives, optimal working conditions, relevant training and maintenance of competence issues, and community support.