Geographic distribution of primary care physicians in Japan and Britain

Inequality in the distribution of resources in the health sector before and after the Health Transformation Plan in Qazvin, Iran

BACKGROUND

The equitable distribution of healthcare resources represents a paramount objective in the realm of global health systems. Thus, the present study sought to assess the fairness in the allocation of health resources at Qazvin University of Medical Sciences (QUMS), both prior to and subsequent to the implementation of the Health Transformation Plan (HTP) using the Gini coefficient and the Hirschman-Herfindahl index (HHI).

METHODS

This descriptive-analytical study aimed to investigate the distribution of healthcare resources among general practitioners (GPs), specialists, and subspecialists employed at QUMS between 2011 and 2017. Demographic data pertaining to the cities were obtained from the statistical yearbooks of the Statistical Center of Iran, while information regarding the healthcare workforce was extracted from QUMS records. The analysis utilized two key measures, namely the Gini coefficient and the HHI, to assess the fairness of resource distribution. Data analysis was performed using Microsoft Excel 2016 and the Stata statistical software.

RESULTS

The highest number of GPs, specialists, and subspecialists was observed in 2014, 2017, and 2017, respectively, while the lowest number was recorded in 2016, 2011, and 2015, respectively. From 2011 to 2017, the Gini coefficient for GPs ranged between 0.61 and 0.63. Among specialists, the lowest Gini coefficient value was observed in 2015 (0.57), while the highest was recorded in 2017 (0.60). The Gini coefficient for subspecialists remained constant at 0.52 from 2011 to 2017. The HHI revealed a high concentration of GPs in the cities of Qazvin province. Although the disparity gradually decreased in the specialties of eye, ear, nose, and throat, and pediatrics, the concentration still persists in Qazvin. In general surgery, the index value is low, indicating some level of inequality. In anesthesia and neurology, the index value decreased after the HTP and reached 5700; however, achieving equality (below 1000) still requires further efforts. No significant change in the index was observed after the HTP in specialties such as neurosurgery, rehabilitation, and nuclear medicine. Subspecialists also exhibited a concentration in the city of Qazvin.

CONCLUSION

Based on the analysis of the Gini and HHI, it is evident that the distribution of GPs has not undergone significant changes following the implementation of the HTP. The Gini coefficient, which ranges from 0.4 to 0.6, indicates a high to complete level of inequality in the distribution of specialists and subspecialists. Moreover, the HHI exceeds 1000, reflecting a concentration of resources in specific areas. As a result, the HTP has not yet achieved its goal of ensuring a fair distribution of human resources. To address this issue, it is recommended to redesign distribution policies, including the allocation of physical health resources, such as specialized hospitals, beds, and medical equipment. Additionally, increasing student admissions in specialized and subspecialized fields and implementing tariff incentives can contribute to a more equitable distribution of resources. By aligning distribution policies with the principle of fairness, the healthcare system can better address the issue of resource distribution.

The Attributes of Physicians Assigned to Rural Clinics Designated for Areas without Physicians in Japan

In Japan, there are rural clinics designated for areas without physicians to ensure the availability of medical care for rural area residents. The purpose of this study was to clarify the attributes of physicians working in the rural clinics. Using the 2018 Ministry of Health, Labour and Welfare data in Japan, we compared the attributes and board certifications of physicians in rural clinics with those of physicians in other clinics. The age group with the highest percentage of physicians was the over 70 group (16%) and the early 30s group (15%) at rural clinics; however, the highest percentage of physicians at other clinics was the 70 over group (20%) and the early 60s group (16%). The number of physicians working in the internal medicine field at rural clinics was 550 (89%). There were 147 (27%) board-certified physicians in that field. Among them, the number of board certifications in internal medicine, surgery, and other than internal medicine or surgery were 79 (54%), 17 (12%), and 51 (35%), respectively. The proportion of board-certified surgery physicians within the internal medicine field in rural clinics was significantly higher than in other clinics (5%). In rural clinics, the age distribution of physicians was different from that in other clinics, and many of the physicians worked in the internal medicine field, but some of them seemed to have a mismatch between their board-certifications and their fields of practice. Further studies are necessary to clarify what the mismatches mean in rural practice.

Temporal-Spatial Evolution and Trend Prediction of the Supply Efficiency of Primary Medical Health Service-An Empirical Study Based on Central and Western Regions of China

China has established a comprehensive primary medical health service system, but the development of primary medical health services in the central and western regions is still unbalanced and insufficient. Based on data from 2010 to 2019, this paper constructs a super efficiency Slack-Based Measure model to calculate the supply efficiency of primary medical health services in 20 provinces and cities in central and western China. Using Kernel density estimation and Markov chain analysis, this paper further analyzes the spatial-temporal evolution of the supply efficiency of primary medical health services in central and western China, and also predicts the future development distribution through the limiting distribution of Markov chain to provide a theoretical basis for promoting the sinking of high-quality medical resources to the primary level. The results show that firstly, during the observation period, the center of the Kernel density curve moves to the left, and the main peak value decreases continuously. The main diagonal elements of the traditional Markov transition probability matrix are 0.7872, 0.5172, 0.8353, and 0.7368 respectively, which are significantly larger than other elements. Secondly, when adjacent to low state and high state, it will develop into convergence distributions of 0.7251 and 0.8243. The supply efficiency of primary medical health services in central and western China has the characteristics of high (Ningxia) and low (Shaanxi) aggregation respectively, but the aggregation trend is weakened. Thirdly, the supply efficiency of health services has the stability of keeping its own state unchanged, but the transition of state can still occur. The long-term development of the current trend cannot break the distribution characteristics of the high and low clusters, the efficiency will show a downward trend in the next 10-20 years, and still the problem of uneven long-term development emerges.

Analysis of inequality in the distribution of general practitioners in China: evidence from 2012 to 2018

Aim:

This paper aims to analyze the inequalities in general practitioner (GP) distribution in China.

Background:

GPs-based primary health care (PHC) has been implemented from 2011 in China, aiming to improve the accessibility and quality of basic medical and healthcare services. GPs in China, as the gatekeeper of people’s health, mainly undertake integrated health services at the grass-roots level.

Methods:

The number of GPs and inequality in GPs distribution from 2012 to 2018 was analyzed by the Lorenz Curve/Gini coefficient and Theil L index. Data were extracted from China Health Statistical Yearbook 2013–2019.

Findings:

The demographic Gini coefficient of GPs changed from 2012 (0.234) to 2018 (0.167), showing high equality in China. In contrast, the Thiel L index from 2012 (0.372) to 2018 (0.345) showed less equality. The decomposition of Thiel L index implicated the inequalities within the divisions. The number of GPs in China shows a fast growth trend since the general practice system established, and the GPs distribution becomes more demographically equitable. However, the shortage of GPs and inequality in their distribution remains severe. More incentive and supportive policies need to be made to enhance the quantity, quality, and structure of GPs in China.

Bayesian estimation of the effect of health inequality in disease detection

BACKGROUND

Measuring health inequality is essential to ensure that everyone has equal accessibility to health care. Studies in the past have continuously presented and showed areas or groups of people affected by various inequality in accessing the health resources and services to help improve this matter. Alongside, disease prevention is as important to minimise the disease burden and improve health and quality of life. These aspects are interlinked and greatly contributes to one's health.

METHOD

In this study, the Gini coefficient and Lorenz curve are used to give an indication of the overall health inequality. The impact of this inequality in granular level is demonstrated using Bayesian estimation for disease detection. The Bayesian estimation used a two-component modelling approach that separates the case detection process and incidence rate using a mixed Poisson distribution while capturing underlying spatio-temporal characteristics. Bayesian model averaging is used in conjunction with the two-component modelling approach to improve the accuracy of estimates by incorporating many candidate models into the analysis instead of using fixed component models. This method is applied to an infectious disease, influenza, in Victoria, Australia between 2013 and 2016 and the corresponding primary health care of the state.

RESULT

There is a relatively equal distribution of health resources and services pertaining to general practitioners (GP) and GP clinics in Victoria, Australia. Roughly 80 percent of the population shares 70 percent of the number of GPs and GP clinics. The Bayesian estimation with model averaging revealed that access difficulty to health services impacts both case detection probability and incidence rate. Minimal differences are recorded in the observed and estimated incidence of influenza cases considering social deprivation factors. In most years, areas in Victoria's southwest and eastern parts have potential under-reported cases consistent with their relatively lower number of GP or GP clinics.

CONCLUSION

The Bayesian model estimated a slight discrepancy between the estimated incidence and the observed cases of influenza in Victoria, Australia in 2013-2016 period. This is consistent with the relatively equal health resources and services in the state. This finding is beneficial in determining areas with potential under-reported cases and under-served health care. The proposed approach in this study provides insight into the impact of health inequality in disease detection without requiring costly and time-extensive surveys and relying mainly on the data at hand. Furthermore, the application of Bayesian model averaging provided a flexible modelling framework that allows covariates to move between case detection and incidence models.

Associations Between Obesity, Physical Inactivity, Healthcare Capacity, and the Built Environment: Geographic Information System Analysis

Background

Obesity is one of the major critical health conditions affecting many people across the world. One of the major causes of obesity is identified to be sedentary lifestyles and physical inactivity, which may be associated with environmental factors.

Objective

The study analyzes variations in obesity and physical inactivity in the State of South Carolina, US, and their association with healthcare capacity and the built environment.

Methods

Data were obtained from different secondary sources and surveys, 2012, and then linked on the county-level using ArcGIS. Global Moran’s I was used to examine the spatial distribution at the state level, and Anselin’s local Moran’s I was used to detect any significant clusters at the county level. Ordinary least squares regression models were calculated for obesity and physical inactivity separately.

Results

More than 70% of SC counties had high levels of obesity and physical inactivity. Spatial analysis showed statistical clusters of high obesity, high physical inactivity, and low access to exercise opportunities in rural areas compared to urban areas. Conversely, clusters of high density of health-care facilities appeared in urban areas. Through the regression models, the density of primary care physicians (p = 0.025) and access to exercise opportunities (p = 0.075) were negatively associated with obesity, while the low perception of own health (p = 0.001) and obesity rate (0.011) were positively associated with physical inactivity.

Conclusion

GIS was useful to illustrate and identify significant geographic variations and high clusters of obesity and physical inactivity in rural areas, compared with high clusters of access to exercise opportunities and health-care facilities in urban areas. The international health community is encouraged to utilize spatial information systems to examine variations and recommend evidence-based recommendations to redistribute equitable public health efforts. The development of strategies and initiatives toward reducing variation in health and sustainable development is key to promote the population wellbeing.

GIS mapping of healthcare practices: do older adults have equitable access to dental and medical care in the UK?

Introduction Considering an ageing population with increasing comorbidities, access to oral and general healthcare is a growing concern. This study aimed to identify and compare access to dental and general practices. This study further aimed to ascertain if there exists a socioeconomic distribution of dental and general practices among older adults.Materials and methods A total of 13,007 dental practices and 13,759 general practices were mapped using geographic information system software, and overlaid with the UK older adult population and deprivation data by health areas. Data analysis was carried out by creating a geographical distribution map and by using descriptive statistics, Gini coefficients and Lorenz curves.Results NHS Central London Clinical Commissioning Group (CCG) held the highest dental practice-to-population ratio of 958 practices per 100,000 older adults, while NHS Manchester CCG held the highest general practice-to-population ratio of 264.4 general practices per 100,000 older adults. England had the highest Gini coefficients for general and dental practice at 0.214 and 0.195, respectively. Both dental and general practices were socioeconomically distributed among older adults in England, Wales and Northern Ireland, but not in Scotland.Conclusions An increasing proportion of older adults need access to healthcare that is based on clinical need, not the ability to pay; a founding principle of the NHS. This nation-wide study captures inequities in the spatial accessibility for older adults in the UK.

Effect of More Doctors (Mais Médicos) Program on geographic distribution of primary care physicians

This study assesses the effect of More Doctors Program (Programa Mais Médicos - PMM) on the equality in the distribution of primary care physicians (PCPs) in Brazil. Spatial data analysis, Lorenz curve and Gini coefficient were used to evaluate the geographic distribution of PCPs before and after the implementation of PMM (2012 and 2016). Data from 5,564 municipalities were used in the analyses. The results indicate that the distribution of PCPs has become more equal after PMM implementation. Between 2012 and 2016, overall Gini coefficient decreased by 11% from 0.255 to 0.227. At the state level, a statistically significant trend towards a more equal distribution of PCPs was found in 21 out of 26 Brazilian states. However, there still remains a substantial difference in the level of equality in PCP distribution, especially across states, with Gini coefficient ranging from 0.093 to 0.341 in 2016.

The geographical maldistribution of obstetricians and gynecologists in Japan

Background

In Japan, there is a large geographical maldistribution of obstetricians/gynecologists, with a high proportion of females. This study seeks to clarify how the increase in the proportion of female physicians affects the geographical maldistribution of obstetrics/gynecologists.

Methods

Governmental data of the Survey of Physicians, Dentists and Pharmacists between 1996 and 2016 were used. The Gini coefficient was used to measure the geographical maldistribution. We divided obstetricians/gynecologists into four groups based on age and gender: males under 40 years, females under 40 years, males aged 40 years and above, and females aged 40 years and above, and the time trend of the maldistribution and contribution of each group was evaluated.

Results

The maldistribution of obstetricians/gynecologists was found to be worse during the study period, with the Gini coefficient exceeding 0.400 in 2016. The contribution ratios of female physicians to the deterioration of geographical maldistribution have been increasing for those under 40 years and those aged 40 years and above. However, there was a continuous decrease in the Gini coefficient of the two groups.

Conclusions

The increase in the contribution ratio of the female physician groups to the Gini coefficient in obstetrics/gynecology may be due to the increased weight of these groups. The Gini coefficients of the female groups were also found to be on a decline. Although this may be because the working environment for female physicians improved or more female physicians established their practice in previously underserved areas, such a notion needs to be investigated in a follow-up study.

Geographic distribution of eye-care practitioners in Aotearoa/New Zealand: implications for future eye health workforce

BACKGROUND

The New Zealand Ministry of Health provides funding for the delivery of health care across regions via 20 District Health Boards. Funding includes the subsidisation of therapeutic pharmaceutical agents/drugs. The distribution of optometrists and ophthalmologists across the regions was investigated to understand the accessibility of eye care in New Zealand. Changes made to the optometrists' scope of practice in 2005 and in 2014 increased the range of drugs that suitably qualified optometrists could prescribe. Therefore, the distribution of optometrists authorised to prescribe drugs and those not authorised to prescribe drugs was also investigated.

METHODS

Information from the New Zealand Optometrists and Dispensing Opticians Board register and information from the Medical Council's website were used to create a database of ophthalmic practitioners and their locations. The χ² goodness-of-fit test was carried out to determine whether the distribution of the number of practitioners across the regions was in proportion to the population of the regions.

RESULTS

Ophthalmologists were distributed across the regions in proportion to the regional population size. However, optometrists were concentrated in Auckland and other regions with high populations. Optometrists authorised to prescribe drugs comprised over 74 per cent of optometrists and were the majority of optometrists in most regions. Many of the regions with populations less than 200,000 had high population-to-practitioner ratios, indicating that they may not have sufficient numbers of ophthalmic practitioners in order to provide for the ocular needs of the community.

CONCLUSION

Better distribution of the optometric workforce could make eye care more accessible in many regions of New Zealand.

The disequilibrium in the distribution of the primary health workforce among eight economic regions and between rural and urban areas in China

Background

Equity is one of the major goals of China’s new medical reforms launched in 2009. This study aimed to analyze the disequilibrium in primary health care (PHC) workforce among various economic zones in China and to compare the fairness between urban and rural areas since the implementation of the new medical reforms.

Method

According to China’s 11th Five-Year Plan, China is divided into eight economic regions. The data of this study were obtained from China Statistical Yearbook 2009–2016. The Atkinson index was used to depict the trend of PHC workforce fairness; the Gini coefficient was used to compare the fairness of workforce distribution between urban and rural areas; the health resource agglomeration degree was used to analyze the distributional equity of the workforce in the eight regions; and the Theil Index was used to compare the fairness of urban and rural workforce distribution across eight regions.

Result

The Atkinson index indicated that the equity of the entire PHC workforce allocation had generally improved during the new medical reforms; the Gini coefficient indicated that the fairness of the entire workforce allocation had improved in cities, but only the nurse allocation became fairer in rural areas. The agglomeration degree and the Theil index indicated that the fairness gaps across the eight regions were still large. These analyses differed from previous studies where China was divided into western, central and eastern regions. In what was previously defined as eastern region, the northeast was under-resourced, while the eastern coastal areas were observing a resource surplus. In western region, we found that the fairness in the northwest was significantly worse than southwest.

Conclusion

In China, the distribution of healthcare workforce has been improved with continuous effort. The gaps in the distribution of PHC workforce across different economic regions and between urban and rural areas are still large, with different regions facing different problems. The government should consider the population and geographical factors in allocation of PHC workforce, especially nurses.

Mobile medical services and experiential learning in community-based clinical clerkships enhancing medical students' positive perceptions of community healthcare

Objective: Previous studies have investigated medical students’ interest in family medicine, as well as their intentions to work in rural areas after taking part in community-based clinical clerkships. Community-based clerkships are designed to teach medical students community healthcare and to increase the number of physicians working in rural communities following their graduation. However, few studies have examined which clerkship experiences, specifically, enhance medical students’ positive perceptions on community healthcare. This study aimed to examine the association between experiential learning in community-based clerkships and students’ positive perceptions on community healthcare.

Patients and Methods: From 2015 to 2017, we conducted a questionnaire survey of 290 final year medical students, before and after completion of their community-based clerkships. The survey asked the students about their perceptions (categorized into “Worthwhile” and “Confident”) of community healthcare and experiential learning during their clerkships. We assessed 13 medical learning areas involving healthcare, medical care, welfare, and nursing care practice. Multivariable logistic regression was used to evaluate the factors associated with positive student perceptions.

Results: Of the 290 students, 265 (91.3%) completed both the pre- and post-questionnaires. Of these, 124 (46.8%) were female, 67 (25.2%) were from small towns (of <100,000 people), and 87 (32.8%) selected clinical clerkships within depopulated areas. A total of 205 (73.3%) students reported positive perceptions on community healthcare. There was a significant association discovered between students’ positive perceptions on community-based healthcare and them taking part in experiential learning in mobile medical services (43 [16.2%] students experienced mobile medical services—adjusted odds ratio 6.65, 95%, confidence intervals 1.67–26.4, p = 0.007).

Conclusion: Medical students’ positive perceptions on community healthcare were discovered to be associated with them taking part in experiential learning in mobile medical services during their community-based clerkships.

Inequality in distribution of burn facilities in Iran

Background: Inequality in the distribution of medical equipment and facilities has mainly been observed in health centers and, particularly, in governmental hospitals in each country. This study aimed to assess inequality in the distribution of burn facilities in Iran, including burn beds and specialist physicians needed for burn patients in 2017. Methods: This was a descriptive-analytic study, in which statistical records of the Ministry of Health and Medical Education for 2017 and the Population and Housing Report of 2016 of the Statistical Centre of Iran were used. The main variables studied were number of burn beds and number of general surgeons and plastic surgeons in medical universities in the provinces of Iran. Inequality in the distribution of these variables was evaluated using the Gini coefficient and the Lorenz curve. Excel 2010 software was used for data analysis. Results: In 55% of the provinces, the number of beds per capita for 100 000 population was lower than the average of Iran (1.26 beds of burn ward), and in 45% of the provinces, it was higher than the average of Iran in terms of this index. The results showed that burn beds were distributed unevenly in medical universities (G=0.42). However, the provincial distribution of these beds had a favorable condition (G=0.21). Also, the numerical value of the Gini coefficient showed the alert status in the distribution of specialist physicians based on the university distribution (G=0.51). Conclusion: Although solving the problems related to equality in the distribution of health resources is not an easy task, assessing this issue has a great impact on improving the policymaking procedures and allocating the health system resources. For the first time, this study presented some policies to avoid centralization and prevent some metropolitan cities from turning into cities with limited burn facilities through a comprehensive reviewing of the distribution of the main sources needed by the Iranian burn patients.

Workforce crisis in primary healthcare worldwide: Hungarian example in a longitudinal follow-up study

OBJECTIVE

The study was designed to explore the development of the general practitioner (GP) shortage in primary care and its characteristics in Hungary.

DESIGN

Longitudinal follow-up study over the decade 2007-2016.

METHODS

Analyses were performed on changes in number, age and sex of GPs by practice type (adult, paediatric and mixed), as well as on their geographical distribution and migration between areas characterised by deprivation index (DI) at municipality level. The association between deprivation and vacancy for GPs was studied by risk analysis. The number of population underserved was defined by DI quintile.

SETTING AND SUBJECTS

The study involved all general practices and GPs in the period examined.

MAIN OUTCOME MEASURE

It is showed that the number of general practices with unfilled GP posts was increasing exponentially, mainly in the most deprived areas of the country.

RESULTS

A decrease in the number of GPs in all types of practices, especially in mixed (by 7.7%; p<0.001) and paediatric (by 6.5%; p<0.001) ones, was shown; the number of adult practices with unfilled GP posts doubled, while the number of paediatric practices with a vacancy for a paediatrician more than tripled. The average age of GPs was increased by 3.7 years (p<0.001) in adult, by 5.4 years (p<0.001) in paediatric and by 4.2 years (p<0.001) in mixed practices. In 2007, 52.27% (95% CI 51.03 to 53.5) of the GPs were women, and this rate increased to 56.19% (95% CI 54.93 to 57.44) by the end of the decade. An exponential association between relative vacancy rate and deprivation was confirmed. As a result of the migration of GPs, in the most deprived areas, the number of GPs decreased by 8.43% (95% CI 5.86 to 10.99).

CONCLUSIONS

The workforce crisis in Hungarian primary care is progressively deepening and resulting in more severe inequity in access to healthcare.

Measuring spatio-temporal accessibility to emergency medical services through big GPS data

Medical accessibility is an important indicator for evaluating the effectiveness of public health services. However, the previous medical accessibility studies mainly focus on spatial accessibility without considering temporal variation in population distribution which is significant for evaluating access to emergency medical service (EMS). This paper proposes a model of spatio-temporal accessibility to EMS called ST-E2SFCA based on adapting the enhanced two-step floating catchment area (E2SFCA) method. We apply our method to the greater Tokyo area for a large volume of GPS dataset with millions of users and compare the accessibility difference over space and time. To evaluate our model, we also analyze the distinction of our model over different weight sets and compare the performance of ST-E2SFCA with the traditional E2SFCA. The result shows that our method can illustrate the temporal difference and is suitable for measuring the spatio-temporal accessibility to EMS, thus can guide the hospital location selection and urban planning.

Human resources for health: A narrative review of adequacy and distribution of clinical and nonclinical human resources in hospitals of Iran

INTRODUCTION

Human resource supply is considered as one of the most vital factors in achieving organizational goals, and human resources are the most valuable factor in the production and delivery of services. Labor shortages and surpluses could downgrade the quality of services offered to patients. Considering the seriousness of this issue, this study aimed to investigate the status of human resources in Iran hospitals.

METHODS

The narrative review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The key terms "Human Resource," "Human Resource Management," "Staff," "Workforce," "Hospital," "emergency," "staff nursing," "medical," "clinical personnel," "administration," "physician personnel," "non clinical personnel," "hospital personnel," "human development," and "Iran" were used in combination with Boolean operators OR and AND. The Institute for Scientific Information's Web of Science, PubMed, Scopus, ScienceDirect, Ovid, ProQuest, Wiley, Google Scholar, and the Persian database were searched.

RESULTS

The research findings revealed that Iran's hospitals have no uniform distribution of human resources. In spite of the concentration of labor forces in some positions (eg, laboratory, radiology, operating room, anesthesia, and midwifery), other positions occupied by physicians and nurses are experiencing serious shortages of human resources, affecting the quality of the provided services.

CONCLUSION

With respect to the study findings, planning to compensate for staff shortages and achieving personnel standard levels as well as providing the grounds for training the heads of wards for proper human resource management and planning would lead to an increase in the efficiency and effectiveness of hospital activities.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Accessibility to Tertiary Stroke Centers in Hokkaido, Japan: Use of Novel Metrics to Assess Acute Stroke Care Quality

BACKGROUND

Both the accessibility and availability of stroke specialists are major determinants of patient outcomes following acute ischemic stroke (AIS). The purpose of this study was to implement novel metrics to assess the accessibility of tertiary stroke centers as well as to evaluate regional disparities in stroke specialists.

METHODS

Using network analysis in a geographic information system, we calculated areas within 30- and 60-minute travel times to facilities providing intravenous recombinant tissue-type plasminogen activator and mechanical thrombectomy. We further evaluated the accessibility for the proportion of the population aged 65 years or older that resided outside of these areas. Uniformity in the geographical distribution of stroke specialists was then evaluated using optimal statistical analysis.

RESULTS

Accessibility varied widely from region to region, with low accessibility being concentrated in rural areas with low population density. Accessibility to facilities providing mechanical thrombectomy was especially low, and 17.8% of elderly individuals lived ≥60 minutes from treatment facilities. In addition, the distribution of stroke specialists was uneven compared with the distribution of hospital beds and full-time medical doctors.

CONCLUSION

The results of this study revealed regional disparities in the spatial accessibility to treatment facilities, as well as in the distribution of stroke specialists in Hokkaido. These findings provide useful information that could be employed to appropriately allocate resources toward the formation of a medical supply system for patients with AIS.

Geographical distribution of medical graduates from a public university

Objective:

To evaluate the geographic distribution and career trajectory of medical graduates and the factors associated with their choice of practice location.

Method:

A cross-sectional study involving graduates from December 2001 to December 2010 was conducted. A self-administered questionnaire collected demographics and geographic information (place of birth, place of residence at the time of medical school admission, place of residency training and practice location), and reason for choosing the current location. Statistical analyses assessed trends in geographic distribution of graduates, and identified factors associated with location choice (through the population density of the location chosen for professional practice).

Results:

A total of 563 graduates completed the questionnaire. Of those, 4.3% (n=24) reported family medicine as their medical specialty, 19.9% (n=112) reported other primary care specialties (internal medicine, pediatrics, surgery and obstetrics-gynecology) and the others chose subspecialties. Larger cities were more likely to be chosen for practice, particularly for newly-graduated doctors. Job invitations received during medical residency training increased the likelihood of choosing high-populated cities. In contrast, job invitations received during medical school increased the likelihood of choosing cities less populated. Amongst those in cities with lower population density, proximity to family members was an additional influencing factor; those who chose more densely populated cities did so because of better infrastructure and recreational options.

Conclusion:

Most of the physicians included in this study pursue subspecialties training and were practicing medicine in large cities. Knowing the multiple factors that influenced the choice of practice location can assist in planning future strategies to reduce physician workforce misdistribution.

Health Equity Indicators for the English NHS: a longitudinal whole-population study at the small-area level

Background

Inequalities in health-care access and outcomes raise concerns about quality of care and justice, and the NHS has a statutory duty to consider reducing them.

Objectives

The objectives were to (1) develop indicators of socioeconomic inequality in health-care access and outcomes at different stages of the patient pathway; (2) develop methods for monitoring local NHS equity performance in tackling socioeconomic health-care inequalities; (3) track the evolution of socioeconomic health-care inequalities in the 2000s; and (4) develop ‘equity dashboards’ for communicating equity findings to decision-makers in a clear and concise format.

Design

Longitudinal whole-population study at the small-area level.

Setting

England from 2001/2 to 2011/12.

Participants

A total of 32,482 small-area neighbourhoods (lower-layer super output areas) of approximately 1500 people.

Main outcome measures

Slope index of inequality gaps between the most and least deprived neighbourhoods in England, adjusted for need or risk, for (1) patients per family doctor, (2) primary care quality, (3) inpatient hospital waiting time, (4) emergency hospitalisation for chronic ambulatory care-sensitive conditions, (5) repeat emergency hospitalisation in the same year, (6) dying in hospital, (7) mortality amenable to health care and (8) overall mortality.

Data sources

Practice-level workforce data from the general practice census (indicator 1), practice-level Quality and Outcomes Framework data (indicator 2), inpatient hospital data from Hospital Episode Statistics (indicators 3–6) and mortality data from the Office for National Statistics (indicators 6–8).

Results

Between 2004/5 and 2011/12, more deprived neighbourhoods gained larger absolute improvements on all indicators except waiting time, repeat hospitalisation and dying in hospital. In 2011/12, there was little measurable inequality in primary care supply and quality, but inequality was associated with 171,119 preventable hospitalisations and 41,123 deaths amenable to health care. In 2011/12, > 20% of Clinical Commissioning Groups performed statistically significantly better or worse than the England equity benchmark.

Limitations

General practitioner supply is a limited measure of primary care access, need in deprived neighbourhoods may be underestimated because of a lack of data on multimorbidity, and the quality and outcomes indicators capture only one aspect of primary care quality. Health-care outcomes are adjusted for age and sex but not for other risk factors that contribute to unequal health-care outcomes and may be outside the control of the NHS, so they overestimate the extent of inequality for which the NHS can reasonably be held responsible.

Conclusions

NHS actions can have a measurable impact on socioeconomic inequality in both health-care access and outcomes. Reducing inequality in health-care outcomes is more challenging than reducing inequality of access to health care. Local health-care equity monitoring against a national benchmark can be performed using any administrative geography comprising ≥ 100,000 people.

Future work

Exploration of quality improvement lessons from local areas performing well and badly on health-care equity, improved methods including better measures of need and risk and measures of health-care inequality over the life-course, and monitoring of other dimensions of equity. These indicators can also be used to evaluate the health-care equity impacts of interventions and make international health-care equity comparisons.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Follow-up study of the regional quota system of Japanese medical schools and prefecture scholarship programmes: a study protocol

INTRODUCTION

Given the shortage of physicians, particularly in rural areas, the Japanese government has rapidly expanded the number of medical school students by adding chiikiwaku (regional quotas) since 2008. Quota entrants now account for 17% of all medical school entrants. Quota entrants are usually local high school graduates who receive a scholarship from the prefecture government. In exchange, they temporarily practise in that prefecture, including its rural areas, after graduation. Many prefectures also have scholarship programmes for non-quota students in exchange for postgraduate in-prefecture practice. The objective of this cohort study, conducted by the Japanese Council for Community-based Medical Education, is to evaluate the outcomes of the quota admission system and prefecture scholarship programmes nationwide.

METHODS AND ANALYSIS

There are 3 groups of study participants: quota without scholarship, quota with scholarship and non-quota with scholarship. Under the support of government ministries and the Association of Japan Medical Colleges, and participation of all prefectures and medical schools, passing rate of the National Physician License Examination, scholarship buy-out rate, geographic distribution and specialties distribution of each group are analysed. Participants who voluntarily participated are followed by linking their baseline information to data in the government's biennial Physician Census. Results to date have shown that, despite medical schools' concerns about academic quality, the passing rate of the National Physician License Examination in each group was higher than that of all medical school graduates.

ETHICS AND DISSEMINATION

The Ethics Committee for Epidemiological Research of Hiroshima University and the Research Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences permitted this study. No individually identifiable results will be presented in conferences or published in journals. The aggregated results will be reported to concerned government ministries, associations, prefectures and medical schools as data for future policy planning.

Unequal socioeconomic distribution of the primary care workforce: whole-population small area longitudinal study

OBJECTIVE

To measure changes in socioeconomic inequality in the distribution of family physicians (general practitioners (GPs)) relative to need in England from 2004/2005 to 2013/2014.

DESIGN

Whole-population small area longitudinal data linkage study.

SETTING

England from 2004/2005 to 2013/2014.

PARTICIPANTS

32,482 lower layer super output areas (neighbourhoods of 1500 people on average).

MAIN OUTCOME MEASURES

Slope index of inequality (SII) between the most and least deprived small areas in annual full-time equivalent GPs (FTE GPs) per 100,000 need adjusted population.

RESULTS

In 2004/2005, inequality in primary care supply as measured by the SII in FTE GPs was 4.2 (95% CI 3.1 to 5.3) GPs per 100,000. By 2013/2014, this SII had fallen to -0.7 (95% CI -2.5 to 1.1) GPs per 100,000. The number of FTE GPs per 100,000 serving the most deprived fifth of small areas increased over this period from 54.0 to 60.5, while increasing from 57.2 to 59.9 in the least deprived fifth, so that by the end of the study period there were more GPs per 100,000 need adjusted population in the most deprived areas than in the least deprived. The increase in GP supply in the most deprived fifth of neighbourhoods was larger in areas that received targeted investment for establishing new practices under the 'Equitable Access to Primary Medical Care'.

CONCLUSIONS

There was a substantial reduction in socioeconomic inequality in family physician supply associated with national policy. This policy may not have completely eliminated socioeconomic inequality in family physician supply since existing need adjustment formulae do not fully capture the additional burden of multimorbidity in deprived neighbourhoods. The small area approach introduced in this study can be used routinely to monitor socioeconomic inequality of access to primary care and to indicate workforce shortages in particular neighbourhoods. http://creativecommons.org/licenses/by/4.0.

[Trends for the Geographic Distribution of Radiological Resources in Hokkaido, Japan: Data Analysis Using Gini Coefficient and Herfindahl-Hirschman Index]

The aim of this study is to analyze the maldistribution and the trends in the geographic distribution of radiological resources in secondary medical areas of Hokkaido. The distribution was measured by combining the Gini coefficient (GC), which is an indicator of inequality of distribution, and the Herfindahl-Hirschman index (HHI), which is mainly used to assess market concentration. Data concerning the distribution of radiological resources, such as CT, MRI, radiotherapy facilities (RTF), radiological technologists (RT), and medical doctors were obtained from official publications. CT was more equally distributed, and RTF was more inequality than other radiological resources in 2014. Radiological resources excluded CT were higher degree of concentration than population distribution, and it showed that they were located relatively more intensively in urban areas than in rural areas. During the period 1999-2014, the GC for CT, MRI, RTF, and RT decreased, while the HHI increased. These trends indicated increased equality of distribution of CT, MRI, RTF, and RT and the concentration in urban areas. This study suggested that GC and HHI could be powerful indicators for allocation planning of medical resources with further analysis of the maldistribution of medical resources.

The cultural context of teaching and learning sexual health care examinations in Japan: a mixed methods case study assessing the use of standardized patient instructors among Japanese family physician trainees of the Shizuoka Family Medicine Program

BACKGROUND

In contrast to many western nations where family medicine is a cornerstone of the primary care workforce, in Japan the specialty is still developing. A number of services within the bailiwick of family medicine have yet to be fully incorporated into Japanese family medicine training programs, especially those associated with sexual health. This gap constitutes a lost opportunity for addressing sexual health-related conditions, including cancer prevention, diagnosis, and treatment. In this mixed methods case study we investigated the perceived acceptability and impact of a standardized patient instructor (SPI) program that trained Japanese family medicine residents in female breast, pelvic, male genital, and prostate examinations.

CASE DESCRIPTION

Building on an existing partnership between the University of Michigan, USA, and the Shizuoka Family Medicine Program, Japan, Japanese family medicine residents received SPI-based training in female breast, pelvic, male genital, and prostate examinations at the University of Michigan. A mixed methods case study targeting residents, trainers, and staff was employed using post-training feedback, semi-structured interviews, and web-based questionnaire.

DISCUSSION AND EVALUATION

Residents' and SPIs' perceptions of the training were universally positive, with SPIs observing a positive effect on residents' knowledge, confidence, and skill. SPIs found specific instruction-related approaches to be particularly helpful, such as the positioning of the interpreter and the timing of interpreter use. SPIs provided an important opportunity for residents to learn about the patient's perspective and to practice newly learned skills. Respondents noted a general preference for gender concordance when providing gender-specific health care; also noted were too few opportunities to practice skills after returning to Japan. For cultural reasons, both residents and staff deemed it would be difficult to implement a similar SPI-based program within Japan.

CONCLUSIONS

While the SPI program was perceived favorably, without sufficient practice and supervision the skills acquired by residents during the training may not be fully retained. Deep-rooted taboos surrounding gender-specific health care appear to be a significant barrier preventing experimentation with SPI-based sexual health training in Japan. The feasibility of implementing a similar training program within Japan remains uncertain. More research is needed to understand challenges and how they can be overcome.

Correlation between pediatrician supply and public health in Japan as evidenced by vaccination coverage in 2010: secondary data analysis

Background

In industrialized countries, assessment of the causal effect of physician supply on population health has yielded mixed results. Since the scope of child vaccination is an indicator of preventive health service utilization, this study investigates the correlation between vaccination coverage and pediatrician supply as a reflection of overall pediatric health during a time of increasing pediatrician numbers in Japan.

Methods

Cross-sectional data were collected from publicly available sources for 2010. Dependent variables were vaccination coverage for measles and diphtheria, pertussis, and tetanus (DPT) by region. The primary predictor of interest was number of pediatricians per 10 000-child population (pediatrician density) at the municipality level. Multivariate logistic regression models were used to estimate associations of interest, conditional on a large range of demographic and infrastructure-related factors as covariates, including non-pediatric physician density, total population, per capita income, occupation, unemployment rate, prevalence of single motherhood, number of hospital beds per capita, length of roads, crime rate, accident rate, and metropolitan area code as urban/rural status. The percentage of the population who completed college-level education or higher in 2010 was included in the model as a proxy for education level.

Results

Pediatrician density was positively and significantly associated with vaccination coverage for both vaccine series. On average, each unit of pediatrician density increased odds by 1.012 for measles (95% confidence interval, 1.010–1.015) and 1.019 for DPT (95% confidence interval, 1.016–1.022).

Conclusions

Policies increasing pediatrician supply contribute to improved preventive healthcare services utilization, such as immunizations, and presumably improved child health status in Japan.

How the government intervention affects the distribution of physicians in Turkey between 1965 and 2000

Introduction

One of the main weaknesses of the health system in Turkey is the uneven distribution of physicians. The diversity among geographical districts was huge in the beginning of the 1960s. After the 1980s, the implementation of a two-year compulsory service for newly graduated physicians is an interesting and specific experience for all countries. The aim of this study is to analyse the distribution of physicians, GPs and specialists between the years 1965-2000 and the efficiency of the strict 15 year government intervention (1981-1995).

Methods

The data used in this study includes the published data by the Ministry of Health and The State Institute of Statistics between the years 1965–2000. Covering 35 years for total physicians, GPs and specialists, Gini coefficients are calculated so as to observe the change in the distribution. In order to measure the efficiency of government intervention, Gini index belonging to the previous 15 years (first period-1965 to 1980) and the last 15 years (second period) of 1981 when the compulsory service was enacted is also analysed including the statistical tests.

Results

In 1965, the Gini for total physician is quite high (0.47), and in 2000 it decreases considerably (0.20). In 1965, the Gini for GPs and the Gini for specialists is 0.44 and 0.52, respectively and in 2000 these values decrease to 0.13 and 0.28, respectively. It is observed that, with this government intervention, the level of diversity has decreased dramatically up to 2000. Regarding to regression, the rate of decrease in Gini index in the second period is higher for the GPs than that of the specialists.

Conclusion

The inequalities in the distribution between GPs and specialists are significantly different; inequality of specialist distribution is higher than the GP. The improvement of the inequality in the physician distribution produced by the market mechanism shows a long period when it is left to its own devices. It is seen that the compulsory service policy is efficient since the physician distribution has improved significantly. The government intervention provides a faster improvement in the GP distribution.

Association between ambulance distance to hospitals and mortality from acute diseases in Japan: national database analysis

OBJECTIVE

The aim of this study was to evaluate the relationship between ambulance distance to hospitals and mortality from acute diseases using the national database in Japan.

DESIGN

Geospatial ecological study.

SETTING

We collected the data of transport distance to hospitals from the Diagnosis Procedure Combination database and that of mortality per 100 000 from some acute diseases from the database of life tables by the Ministry of Health, Labour and Welfare in Japan.

PARTICIPANTS

A total of 108 314 patients (40 882 patients with acute myocardial infarction, 31 632 patients with brain infarction, 4992 patients with subarachnoid hemorrhage, and 30 808 patients with pneumonia) were referred in Japan in 2008.

MAIN OUTCOME MEASURES

We evaluated the association between the mean transport distance to hospitals and the mortality from acute diseases using simple linear regression analysis. This correlation was evaluated separately for each acute disease.

RESULTS

The mean transport distances to hospitals were 8.1 km for acute myocardial infarction, 8.3 km for brain infarction, 9.5 km for subarachnoid hemorrhage, and 7.6 km for pneumonia, whereas the mortalities per 100,000 were 34.6 for acute myocardial infarction, 60.4 for brain infarction, 11.2 for subarachnoid hemorrhage, and 91.6 for pneumonia. Simple linear regression analysis revealed significant positive correlations between transport distance and mortality per 100,000 for acute myocardial infarction and brain infarction (R2 = 0.315 and 0.398, P < .001, respectively). Otherwise, moderate positive correlations between transport distance and mortality per 100,000 were shown for subarachnoid hemorrhage and pneumonia (R2 = 0.112, P < .012 and .233, P < .001, respectively).

CONCLUSIONS

This study suggests that the ambulance distance to hospitals significantly influences the risk of mortality for some acute diseases in Japan. Further studies are needed to confirm this association.

Pediatricians' practice location choice-Evaluating the effect of Japan's 2004 postgraduate training program on the spatial distribution of pediatricians

OBJECTIVES

To explore determinants of change in pediatrician supply in Japan, and examine impacts of a 2004 reform of postgraduate medical education on pediatricians' practice location choice.

METHODS

Data were compiled from secondary data sources. The dependent variable was the change in the number of pediatricians at the municipality ("secondary tier of medical care" [STM]) level. To analyze the determinants of pediatrician location choices, we considered the following predictors: initial ratio of pediatricians per 1000 children under five years of age (pediatrician density) and under-5 mortality as measures of local area need, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004. Basic comparisons of pediatrician coverage in the top and bottom 10% of STMs were conducted to assess inequality in pediatrician supply.

RESULTS

Increased supply was inversely associated with baseline pediatrician density both in the pre-period and post-period. Estimated impact of pediatrician density declined over time (P = 0.026), while opposite trends were observed for measures of residential quality. More specifically, urban centers and the SES composite index were positively associated with pediatrician supply for the post-period, but no such associations were found for the pre-period. Inequality in pediatrician distribution increased substantially after the reform, with the best-served 10% of communities benefitting from five times the pediatrician coverage compared to the least-served 10%.

CONCLUSIONS

Residential quality increasingly became a function of location preference rather than public health needs after the reform. New placement schemes should be developed to achieve more equity in access to pediatric care.

Community participation to design rural primary healthcare services

BACKGROUND

This paper explores how community participation can be used in designing rural primary healthcare services by describing a study of Scottish communities. Community participation is extolled in healthcare policy as useful in planning services and is understood as particularly relevant in rural settings, partly due to high social capital. Literature describes many community participation methods, but lacks discussion of outcomes relevant to health system reconfiguration. There is a spectrum of ideas in the literature on how to design services, from top-down standard models to contextual plans arising from population health planning that incorporates community participation. This paper addresses an evidence gap about the outcomes of using community participation in (re)designing rural community health services.

METHODS

Community-based participatory action research was applied in four Scottish case study communities in 2008-10. Data were collected from four workshops held in each community (total 16) and attended by community members. Workshops were intended to produce hypothetical designs for future service provision. Themes, rankings and selections from workshops are presented.

RESULTS

Community members identified consistent health priorities, including local practitioners, emergency triage, anticipatory care, wellbeing improvement and health volunteering. Communities designed different service models to address health priorities. One community did not design a service model and another replicated the current model despite initial enthusiasm for innovation.

CONCLUSIONS

Communities differ in their receptiveness to engaging in innovative service design, but some will create new models that fit in a given budget. Design diversity indicates that context influences local healthcare planning, suggesting community participation impacts on design outcomes, but standard service models maybe useful as part of the evidence in community participation discussions.

The impact of centralization of obstetric care resources in Japan on the perinatal mortality rate

Objective. We investigated the effects of the centralization of obstetricians and obstetric care facilities on the perinatal mortality rate in Japan. Methods. We used the Gini coefficient as an index to represent the centralization of obstetricians and obstetric care facilities. The Gini coefficients were calculated for the number of obstetricians and obstetric care facilities of 47 prefectures using secondary medical care zones as units. To measure the effects of the centralization of obstetricians and obstetric care facilities on the outcomes (perinatal mortality rates), we performed multiple regression analysis using the perinatal mortality rate as the dependent variable. Results. Obstetric care facilities were more evenly distributed than obstetricians. The perinatal mortality rate was found to be significantly negatively correlated with the number of obstetricians per capita and the Gini coefficient of obstetric care facilities. The latter had a slightly stronger effect on the perinatal mortality rate. Conclusion. The centralization of obstetric care facilities can improve the perinatal mortality rate, even when increasing the number of obstetricians is difficult.

The impact of Japan's 2004 postgraduate training program on intra-prefectural distribution of pediatricians in Japan

Objective

Inequity in physician distribution poses a challenge to many health systems. In Japan, a new postgraduate training program for all new medical graduates was introduced in 2004, and researchers have argued that this program has increased inequalities in physician distribution. We examined the trends in the geographic distribution of pediatricians as well as all physicians from 1996 to 2010 to identify the impact of the launch of the new training program.

Methods

The Gini coefficient was calculated using municipalities as the study unit within each prefecture to assess whether there were significant changes in the intra-prefectural distribution of all physicians and pediatricians before and after the launch of the new training program. The effect of the new program was quantified by estimating the difference in the slope in the time trend of the Gini coefficients before and after 2004 using a linear change-point regression design. We categorized 47 prefectures in Japan into two groups: 1) predominantly urban and 2) others by the definition from OECD to conduct stratified analyses by urban-rural status.

Results

The trends in physician distribution worsened after 2004 for all physicians (p value<.0001) and pediatricians (p value = 0.0057). For all physicians, the trends worsened after 2004 both in predominantly urban prefectures (p value = 0.0012) and others (p value<0.0001), whereas, for pediatricians, the distribution worsened in others (p value = 0.0343), but not in predominantly urban prefectures (p value = 0.0584).

Conclusion

The intra-prefectural distribution of physicians worsened after the launch of the new training program, which may reflect the impact of the new postgraduate program. In pediatrics, changes in the Gini trend differed significantly before and after the launch of the new training program in others, but not in predominantly urban prefectures. Further observation is needed to explore how this difference in trends affects the health status of the child population.

Geographical movement of doctors from education to training and eventual career post: UK cohort studies

OBJECTIVE

To investigate the geographical mobility of UK-trained doctors.

DESIGN

Cohort studies conducted by postal questionnaires.

SETTING

UK.

PARTICIPANTS

A total 31,353 UK-trained doctors in 11 cohorts defined by year of qualification, from 1974 to 2008.

MAIN OUTCOME MEASURES

Location of family home prior to medical school, location of medical school, region of first training post, region of first career post. Analysis for the UK divided into 17 standard geographical regions.

RESULTS

The response rate was 81.2% (31,353/45,061; denominators, below, depended on how far the doctors' careers had progressed). Of all respondents, 36% (11,381/31,353) attended a medical school in their home region and 48% (10,370/21,740) undertook specialty training in the same region as their medical school. Of respondents who had reached the grade of consultant or principal in general practice in the UK, 34% (4169/12,119) settled in the same region as their home before entering medical school. Of those in the UK, 70% (7643/10,887) held their first career post in the same region as either their home before medical school, or their medical school or their location of training. For 18% (1938/10,887), all four locations - family home, medical school, place of training, place of first career post - were within the same region. A higher percentage of doctors from the more recent than from the older cohorts settled in the region of their family home.

CONCLUSION

Many doctors do not change geographical region in their successive career moves, and recent cohorts appear less inclined to do so.

The impact of travel time on geographic distribution of dialysis patients

Backgrounds

The geographic disparity of prevalence rates among dialysis patients is unclear. We evaluate the association between travel time to dialysis facilities and prevalence rates of dialysis patients living in 1,867 census areas of Hiroshima, Japan. Furthermore, we study the effects of geographic features (mainland or island) on the prevalence rates and assess if these effects modify the association between travel time and prevalence.

Methods

The study subjects were all 7,374 people that were certified as the “renal disabled” by local governments in 2011. The travel time from each patient to the nearest available dialysis facility was calculated by incorporating both travel time and the capacity of all 98 facilities. The effect of travel time on the age- and sex-adjusted standard prevalence rate (SPR) and 95% confidence intervals (CIs) at each census area was evaluated in two-level Poisson regression models with 1,867 census areas (level 1) nested within 35 towns or cities (level 2). The results were adjusted for area-based parameters of socioeconomic status, urbanity, and land type. Furthermore, the SPR of dialysis patients was calculated in each specific subgroup of population for travel time, land type, and combination of land type and travel time.

Results

In the regression analysis, SPR decreased by 5.2% (95% CI: −7.9–−2.3) per 10-min increase in travel time even after adjusting for potential confounders. The effect of travel time on prevalence was different in the mainland and island groups. There was no travel time-dependent SPR disparity on the islands. The SPR among remote residents (>30 min from facilities) in the mainland was lower (0.77, 95% CI: 0.71–0.85) than that of closer residents (≤30 min; 0.95, 95% CI: 0.92–0.97).

Conclusions

The prevalence of dialysis patients was lower among remote residents. Geographic difficulties for commuting seem to decrease the prevalence rate.

Geographic distribution of healthcare resources, healthcare service provision, and patient flow in Japan: a cross sectional study

Healthcare systems in developed countries are facing the challenge of dealing with changing social structures as a result of rapidly aging populations. This study examines the relationship among the geographical distribution of healthcare resources, healthcare service provision, and interregional patient flow in Japan. A cross-sectional study was performed using data from healthcare-related public surveys conducted in 2008, together with social, economic, and environmental variables. The geographical units of analysis were 348 Secondary Healthcare Service Areas, which provide and manage most healthcare services in Japan. The equity of the distribution of physicians among hospitals and clinics was evaluated using the Lorenz curve and the Gini coefficient. Multiple regression analysis was used to examine the relationships between the inpatient flow ratio and selected variables. Next, the 348 Secondary Healthcare Service Areas were divided into tertiles according to the inpatient flow ratio, and differences among these variables were examined using Bonferroni's correction for multiple comparisons. The Gini coefficient for physician distribution among hospitals was 0.209 and was 0.165 among clinics. Multiple regression analysis showed that hospital physician density, the elderly ratio, and hospital bed density were all correlated with the inpatient flow ratio (β = 0.396, -0.576, 0.425, respectively; R(2) = 0.622, all ps < 0.001). Healthcare resources were significantly more scarce in the lowest tertile (outflow group) than in other groups in both hospitals and clinics. The provision of healthcare services was also imbalanced among tertiles. Our results imply that there is a need for reconstituting the geographical distribution of healthcare resources in Japan. Further research and healthcare-related databases are also needed to facilitate the creation of a more balanced geographical distribution and of a more effective healthcare system in Japan.

The impact of rural hospital closures on equity of commuting time for haemodialysis patients: simulation analysis using the capacity-distance model

Background

Frequent and long-term commuting is a requirement for dialysis patients. Accessibility thus affects their quality of lives. In this paper, a new model for accessibility measurement is proposed in which both geographic distance and facility capacity are taken into account. Simulation of closure of rural facilities and that of capacity transfer between urban and rural facilities are conducted to evaluate the impacts of these phenomena on equity of accessibility among dialysis patients.

Methods

Post code information as of August 2011 of all the 7,374 patients certified by municipalities of Hiroshima prefecture as having first or third grade renal disability were collected. Information on post code and the maximum number of outpatients (capacity) of all the 98 dialysis facilities were also collected. Using geographic information systems, patient commuting times were calculated in two models: one that takes into account road distance (distance model), and the other that takes into account both the road distance and facility capacity (capacity-distance model). Simulations of closures of rural and urban facilities were then conducted.

Results

The median commuting time among rural patients was more than twice as long as that among urban patients (15 versus 7 minutes, p < 0.001). In the capacity-distance model 36.1% of patients commuted to the facilities which were different from the facilities in the distance model, creating a substantial gap of commuting time between the two models. In the simulation, when five rural public facilitiess were closed, Gini coefficient of commuting times among the patients increased by 16%, indicating a substantial worsening of equity, and the number of patients with commuting times longer than 90 minutes increased by 72 times. In contrast, closure of four urban public facilities with similar capacities did not affect these values.

Conclusions

Closures of dialysis facilities in rural areas have a substantially larger impact on equity of commuting times among dialysis patients than closures of urban facilities. The accessibility simulations using thecapacity-distance model will provide an analytic framework upon which rational resource distribution policies might be planned.

Cohort profile: the ages 2003 cohort study in Aichi, Japan

Background

The longevity of Japanese is thought to be associated with psychosocial factors such as sense of coherence, social support, and social capital. However, the actual factors responsible and the extent of their contribution to individual health status are not known.

Methods

The Aichi Gerontological Evaluation Study (AGES) 2003 Cohort Study is a prospective cohort study of community-dwelling, activities of daily living-independent people aged 65 or older living in 6 municipalities in Chita peninsula, Aichi Prefecture, Japan. Information on psychosocial factors and other individual- and community-level factors was collected in the second half of 2003 using a baseline questionnaire. Vital status and physical and cognitive decline have been followed using data derived from long-term care insurance certification. Geographical information on the study participants was also obtained.

Results

A total of 13 310 (6508 men; 6802 women) study participants were registered in the study. For an interim report, we followed the cohort for 48 months, yielding 24 753 person-years of observation among men and 26 456 person-years among women.

Conclusions

The AGES 2003 Cohort Study provides useful evidence for research in social epidemiology, gerontology, and health services.

Geographical distributions of physicians in Japan and US: Impact of healthcare system on physician dispersal pattern

OBJECTIVES

This study examined the effect of increased physician numbers overall on the geographic distribution of the physicians in Japan and the US.

METHODS

Equity of physician distribution with reference to community population and community income was evaluated in all municipalities in Japan, and all counties in the US.

RESULTS

Between 1980 and 2005, Japan and the US experienced a 55% and 47% increase in the number of physicians per unit population, respectively. The Gini coefficients against population were at similar values between Japan and the US, and have been almost unchanged in the past 25 years in both countries. The Gini coefficient against income in the US was lower than the coefficient in Japan, and the US value has decreased since 1980. Correlation between physician-to-population ratio and per capita income among the communities was stronger in the US than in Japan and has increasingly been strengthened during the period examined.

CONCLUSIONS

In spite of constant growth of physician numbers, physicians do not diffuse according to population distribution in both countries. Rather, US physicians seem to diffuse according to income distribution. In order to reverse the continuing maldistribution of physicians, political intervention is required in both countries.