Realizing neighbourhood potential? The role of the availability of health care services on contact with a primary care physician

Geographic Access to Pediatric Orthopedic Surgeons in the United States: An Analysis of Sociodemographic Factors

BACKGROUND

It is unclear how pediatric orthopedic surgeons are geographically distributed relative to their patients. The purpose of this study was to evaluate the geographic distribution of pediatric orthopedic surgeons in the United States.

MATERIALS AND METHODS

County-level data of actively practicing pediatric orthopedic surgeons were identified by matching several registries and membership logs. Data were used to calculate the distance between counties and nearest surgeon. Counties were categorized as "surgeon clusters" or "surgeon deserts" if the distance to the nearest surgeon was less than or greater than the national average and the average of all neighboring counties, respectively. Cohorts were then compared for differences in population characteristics using data obtained from the 2020 American Community Survey.

RESULTS

A total of 1197 unique pediatric orthopedic surgeons were identified. The mean distance to the nearest pediatric orthopedic surgeon for a patient residing in a surgeon desert or a surgeon cluster was 141.9±53.8 miles and 30.9±16.0 miles, respectively. Surgeon deserts were found to have lower median household incomes (P<.001) and greater rates of children without health insurance (P<.001). Multivariate analyses showed that higher Rural-Urban Continuum codes (P<.001), Area Deprivation Index scores (P<.001), and percentage of patients without health insurance (P<.001) all independently required significantly greater travel distances to see a pediatric orthopedic surgeon.

CONCLUSION

Pediatric orthopedic surgeons are not equally distributed in the United States, and many counties are not optimally served. Additional studies are needed to identify the relationship between travel distances and patient outcomes and how geographic inequalities can be minimized. [Orthopedics. 202x;4x(x):xx-xx.].

Geographic access to pediatric neurosurgeons in the USA: an analysis of sociodemographic factors

PURPOSE

Geographic access to physicians has been shown to be unevenly distributed in the USA, with those in closer proximity having superior outcomes. The purpose of this study was to describe how geographic access to pediatric neurosurgeons varies across socioeconomic and demographic factors.

METHODS

Actively practicing neurosurgeons were identified by matching several registries and membership logs. This data was used to find their primary practice locations and the distance the average person in a county must travel to visit a surgeon. Counties were categorized into "surgeon deserts" and "surgeon clusters," which were counties where providers were significantly further or closer to its residents, respectively, compared to the national average. These groups were also compared for differences in population characteristics using data obtained from the 2020 American Community Survey.

RESULTS

A total of 439 pediatric neurosurgeons were identified. The average person in a surgeon desert and cluster was found to be 189.2 ± 78.1 miles and 39.7 ± 19.6 miles away from the nearest pediatric neurosurgeon, respectively. Multivariate analyses showed that higher Rural-Urban Continuum (RUC) codes (p < 0.001), and higher percentages of American Indian (p < 0.001) and Hispanic (p < 0.001) residents were independently associated with counties where the average person traveled significantly further to surgeons.

CONCLUSION

Patients residing in counties with greater RUC codes and higher percentages of American Indian and Hispanic residents on average need to travel significantly greater distances to access pediatric neurosurgeons.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Asian American Enclaves and Healthcare Accessibility: An Ecologic Study Across Five States

INTRODUCTION

Access to primary care has been a long-standing priority for improving population health. Asian Americans, who often settle in ethnic enclaves, have been found to underutilize health care. Understanding geographic primary care accessibility within Asian American enclaves can help to ensure the long-term health of this fast-growing population.

METHODS

U.S. Census data from five states (California, Florida, New Jersey, New York, and Texas) were used to develop and describe census-tract level measures of Asian American enclaves and social and built environment characteristics for years 2000 and 2010. The 2-step floating catchment area method was applied to National Provider Identifier data to develop a tract-level measure of geographic primary care accessibility. Analyses were conducted in 2022-2023, and associations between enclaves (versus nonenclaves) and geographic primary care accessibility were evaluated using multivariable Poisson regression with robust variance estimation, adjusting for potential area-level confounders.

RESULTS

Of 24,482 census tracts, 26.1% were classified as Asian American enclaves. Asian American enclaves were more likely to be metropolitan and have less poverty, lower crime, and lower proportions of uninsured individuals than nonenclaves. Asian American enclaves had higher primary care accessibility than nonenclaves (adjusted prevalence ratio=1.23, 95% CI=1.17, 1.29).

CONCLUSIONS

Asian American enclaves in five of the most diverse and populous states in the U.S. had fewer markers of disadvantage and greater geographic primary care accessibility. This study contributes to the growing body of research elucidating the constellation of social and built environment features within Asian American enclaves and provides evidence of health-promoting characteristics of these neighborhoods.

Does Geography Play a Role in the Receipt of End-of-Life Care for Advanced Cancer Patients? Evidence from an Australian Local Health District Population-Based Study

Objectives: To assess the influence of geographic remoteness on health care utilization at end of life (EOL) by people with advanced cancer in a geographically diverse Australian local health district, using two objective measures of rurality and travel-time estimations to health care facilities. Methods: This retrospective cohort study examined the association between rurality (using the Modified Monash Model) and travel-time estimation, and demographic and clinical factors, with the receipt of >1 inpatient and outpatient health service in the last year of life in multivariate models. The study cohort comprised of 3546 patients with cancer, aged ≥18 years, who died in a public hospital between 2015 and 2019. Results: Compared with decedents from metropolitan areas, decedents from some rural areas had higher rates of emergency department visits (small rural towns: aRR 1.29, 95% CI: 1.07-1.57) and ICU admissions (large rural towns: aRR 1.32, 95% CI: 1.03-1.69), but lower rates of acute hospital admissions (large rural towns: aRR 0.83, 95% CI: 0.76-0.90), inpatient palliative care (PC) (regional centers: aRR 0.85, 95% CI: 0.75-0.97), and inpatient radiotherapy (lowest in small rural towns: aRR 0.07, 95% CI: 0.03-0.18). Decedents from rural and regional centers had lower rates of outpatient chemotherapy and radiotherapy use, yet higher rates of outpatient cancer service utilization (p < 0.05). Shorter travel times (10-<30 minutes) were associated with higher rates of inpatient specialist PC (aRR 1.48, 95% CI: 1.09-1.98). Conclusions: Reporting on a series of inpatient and outpatient services used in the last year of life, measures of rurality and travel-time estimates can be useful tools to estimate geographic variation in EOL cancer care provision, with significant gaps uncovered in inpatient PC and outpatient service utilization in rural areas. Policies aimed at redistributing EOL resources in rural and regional communities to reduce travel times to health care facilities could help to reduce regional disparities and ensure equitable access to EOL care services.

Patterns in Geographic Access to Health Care Facilities Across Neighborhoods in the United States Based on Data From the National Establishment Time-Series Between 2000 and 2014

IMPORTANCE

The association between proximity to health care facilities and improved disease management and population health has been documented, but little is known about small-area health care environments and how the presence of health care facilities has changed over time during recent health system and policy change.

OBJECTIVE

To examine geographic access to health care facilities across neighborhoods in the United States over a 15-year period.

DESIGN, SETTING, AND PARTICIPANTS

Using longitudinal business data from the National Establishment Time-Series, this cross-sectional study examined the presence of and change in ambulatory care facilities and pharmacies and drugstores in census tracts (CTs) throughout the continental United States between 2000 and 2014. Between January and April 2019, multinomial logistic regression was used to estimate associations between health care facility presence and neighborhood sociodemographic characteristics over time.

MAIN OUTCOMES AND MEASURES

Change in health care facility presence was measured as never present, lost, gained, or always present between 2000 and 2014. Neighborhood sociodemographic characteristics (ie, CTs) and their change over time were measured from US Census reports (2000 and 2010) and the American Community Survey (2008-2012).

RESULTS

Among 72 246 included CTs, the percentage of non-US-born residents, residents 75 years or older, poverty status, and population density increased, and 8.1% of CTs showed a change in the racial/ethnic composition of an area from predominantly non-Hispanic (NH) white to other racial/ethnic composition categories between 2000 and 2010. The presence of ambulatory care facilities increased from a mean (SD) of 7.7 (15.9) per CT in 2000 to 13.0 (22.9) per CT in 2014, and the presence of pharmacies and drugstores increased from a mean (SD) of 0.6 (1.0) per CT in 2000 to 0.9 (1.4) per CT in 2014. Census tracts with predominantly NH black individuals (adjusted odds ratio [aOR], 2.37; 95% CI, 2.03-2.77), Hispanic/Latino individuals (aOR 1.30; 95% CI, 1.00-1.69), and racially/ethnically mixed individuals (aOR, 1.53; 95% CI, 1.33-1.77) in 2000 had higher odds of losing health care facilities between 2000 and 2014 compared with CTs with predominantly NH white individuals, after controlling for other neighborhood characteristics. Census tracts of geographic areas with higher levels of poverty in 2000 also had higher odds of losing health care facilities between 2000 and 2014 (aOR, 1.12; 95% CI, 1.05-1.19).

CONCLUSIONS AND RELEVANCE

Differential change was found in the presence of health care facilities across neighborhoods over time, indicating the need to monitor and address the spatial distribution of health care resources within the context of population health disparities.

Medical facilities in the neighborhood and incidence of sudden cardiac arrest

BACKGROUND

Medical establishments in the neighborhood, such as pharmacies and primary care clinics, may play a role in improving access to preventive care and treatment and could explain previously reported neighborhood variations in sudden cardiac arrest (SCA) incidence and survival.

METHODS

The Cardiac Arrest Blood Study Repository is a population-based repository of data from adult cardiac arrest patients and population-based controls residing in King County, Washington. We examined the association between the availability of medical facilities near home with SCA risk, using adult (age 18-80) Seattle residents experiencing cardiac arrest (n = 446) and matched controls (n = 208) without a history of heart disease. We also analyzed the association of major medical centers near the event location with emergency medical service (EMS) response time and survival among adult cases (age 18+) presenting with ventricular fibrillation from throughout King County (n = 1537). The number of medical facilities per census tract was determined by geocoding business locations from the National Establishment Time-Series longitudinal database 1990-2010.

RESULTS

More pharmacies in the home census tract was unexpectedly associated with higher odds of SCA (OR:1.28, 95% CI: 1.03, 1.59), and similar associations were observed for other medical facility types. The presence of a major medical center in the event census tract was associated with a faster EMS response time (-53 s, 95% CI: -84, -22), but not with short-term survival.

CONCLUSIONS

We did not observe a protective association between medical facilities in the home census tract and SCA risk, orbetween major medical centers in the event census tract and survival.

How HIV affects health and service use for adults with intellectual and developmental disabilities

OBJECTIVE(S)

Although rates of human immunodeficiency virus (HIV) are similar for individuals with and without intellectual and developmental disabilities (IDD), very little is known about the health needs and service use of those with IDD and HIV. Among a population with IDD, we compared the physical and mental health profiles, as well as general and mental health service use for those with and without HIV.

DESIGN

Retrospective cohort study in Ontario, Canada using linked administrative health and social service databases.

METHODS

The prevalence of physical conditions and mental health disorders, and patterns of service use for any reason and service use for mental health issues were compared among Ontario adults with IDD and HIV (n = 107) and without HIV (n = 63 901) in log-binomial models adjusted for age, sex and neighbourhood income and rurality.

RESULTS

Adults with IDD and HIV were more likely than those without HIV to have three types of mental health disorders: non-psychotic disorders [aRR: adjusted rate ratio (aRR): 1.22 (95% confidence interval (CI): 1.01-1.47)], psychotic disorders [aRR: 1.57 (1.09, 2.28)] and substance use disorders [aRR: 3.52 (2.53, 4.91)]. Adults with IDD and HIV were also more likely to have emergency department visits [aRR: 1.68 (1.42, 1.98)] and hospital admissions [aRR: 2.55 (1.74, 3.73)] for any reason, and to have mental health emergency department visits and/or admissions [aRR: 2.82 (1.90, 4.18)].

DISCUSSION

Adults with IDD and HIV have complex health profiles and greater health service use than HIV-negative adults with IDD. These findings call for closer integration of programs delivered by the HIV and disability sectors to optimise the health of this patient population.

Exploring the social and neighbourhood predictors of diabetes: a comparison between Toronto and Chicago

OBJECTIVES

This report examined the impact and extent that spatial access to primary care physicians (PCPs) and social neighbourhood-/community-level factors have on diabetes prevalence for Toronto and Chicago.

METHODS

The two-step floating catchment area method was used to compute spatial access scores. Bivariate correlation and multivariate linear regression identified the factors that were associated with, and/or predicted, diabetes prevalence.

RESULTS

Potential spatial access to PCPs had no strong associations with diabetes prevalence. Low socio-economic status factors and certain ethnic groups were strongly associated with diabetes prevalence for both cities. For Toronto, South American place of birth, households below poverty and high school-level education predicted diabetes prevalence. African ethnicity and households below poverty predicted diabetes prevalence for Chicago.

CONCLUSION

Although this report found no strong association between diabetes prevalence and access to PCPs, contextual factors significant in past individual-level diabetes studies were associated with diabetes prevalence at the neighbourhood/community level for Toronto and Chicago.

Neighborhood Socioeconomic Status and Primary Health Care: Usual Points of Access and Temporal Trends in a Major US Urban Area

Neighborhood socioeconomic status (SES), an overall marker of neighborhood conditions, may determine residents' access to health care, independently of their own individual characteristics. It remains unclear, however, how the distinct settings where individuals seek care vary by neighborhood SES, particularly in US urban areas. With existing literature being relatively old, revealing how these associations might have changed in recent years is also timely in this US health care reform era. Using data on the Philadelphia region from 2002 to 2012, we performed multilevel analysis to examine the associations of neighborhood SES (measured as census tract median household income) with access to usual sources of primary care (physician offices, community health centers, and hospital outpatient clinics). We found no evidence that residence in a low-income (versus high-income) neighborhood was associated with poorer overall access. However, low-income neighborhood residence was associated with less reliance on physician offices [-4.40 percentage points; 95 % confidence intervals (CI) -5.80, -3.00] and greater reliance on the safety net provided by health centers [2.08; 95 % CI 1.42, 2.75] and outpatient clinics [1.61; 95 % CI 0.97, 2.26]. These patterns largely persisted over the 10 years investigated. These findings suggest that safety-net providers have continued to play an important role in ensuring access to primary care in urban, low-income communities, further underscoring the importance of supporting a strong safety net to ensure equitable access to care regardless of place of residence.

Determinants of initial utilization of community healthcare services among patients with major non-communicable chronic diseases in South China

Background

Although expected to act as gate-keeping primary care providers, as community health service (CHS) facilities are severely under-utilized; Chinese people in both rural and urban areas used predominantly higher-tier facilities for primary care purpose, with significant financial and outcome consequences. This study intends to explore the determinants of initial utilization of CHS among patients with major non-communicable chronic diseases (NCDs) in order to understand the care-seeking behavior among urban and rural residents in South China.

Methods

A multi-stage cluster random sampling methodology was adopted to create a sample of 19,466 adults with NCDs from 7,970 urban households and 32,035 adults with NCDs from 3,860 rural households in Guangdong, China. Interviews and physical examinations were conducted in 2010 to collect data on patient characteristics, medical conditions, and awareness and utilization of healthcare. Descriptive analysis and logistic regression analysis were performed to study utilization patterns and the factors associated with the patterns.

Results

Prevalence of major NCDs in urban areas was significantly higher than that in rural areas (12.55% vs. 8.70%; p<0.001). Second-tier district hospitals were most preferred for initial consultation (46.05% in rural areas vs. 45.32% in urban areas; p<0.001), followed by tertiary general or specialized hospitals (28.39% in rural areas vs. 33.89% in urban areas; p<0.001). The proportion of patients who had initial use of CHS was relatively low (25.56% in rural areas vs. 20.79% in urban areas; p<0.001). Awareness of self-care and the presence of medical insurance were leading factors associated with first contact of CHS facilities in both urban and rural areas.

Conclusion

The study suggests that CHS facilities are not often used as the first contact for patients in both rural and urban areas in south China. Much effect must be made to enhance the gatekeeper system and improve medical insurance coverage in future healthcare reforms.

Local population characteristics and hemoglobin A1c testing rates among diabetic medicare beneficiaries

BACKGROUND

Proposed payment reforms in the US healthcare system would hold providers accountable for the care delivered to an assigned patient population. Annual hemoglobin A1c (HbA1c) tests are recommended for all diabetics, but some patient populations may face barriers to high quality healthcare that are beyond providers' control. The magnitude of fine-grained variations in care for diabetic Medicare beneficiaries, and their associations with local population characteristics, are unknown.

METHODS

HbA1c tests were recorded for 480,745 diabetic Medicare beneficiaries. Spatial analysis was used to create ZIP code-level estimated testing rates. Associations of testing rates with local population characteristics that are outside the control of providers--population density, the percent African American, with less than a high school education, or living in poverty--were assessed.

RESULTS

In 2009, 83.3% of diabetic Medicare beneficiaries received HbA1c tests. Estimated ZIP code-level rates ranged from 71.0% in the lowest decile to 93.1% in the highest. With each 10% increase in the percent of the population that was African American, associated HbA1c testing rates were 0.24% lower (95% CI -0.32--0.17); for identical increases in the percent with less than a high school education or the percent living in poverty, testing rates were 0.70% lower (-0.95--0.46) and 1.6% lower (-1.8--1.4), respectively. Testing rates were lowest in the least and most densely populated ZIP codes. Population characteristics explained 5% of testing rate variations.

CONCLUSIONS

HbA1c testing rates are associated with population characteristics, but these characteristics fail to explain the vast majority of variations. Consequently, even complete risk-adjustment may have little impact on some process of care quality measures; much of the ZIP code-related variations in testing rates likely result from provider-based differences and idiosyncratic local factors not related to poverty, education, or race.

An Extended Kernel Density Two-Step Floating Catchment Area Method to Analyze Access to Health Care

In Portugal the distribution of physicians is considered an appropriate proxy for the distribution of the actual hospital resources and additional information on hospital supply is mostly unavailable, while health care utilization data are also usually absent. A suitable method that can be used to analyze patients' access to hospital health care in countries with such characteristics is the two-step floating catchment area (2SFCA) method, since it requires only the number of physicians to represent supply and the population size to estimate demand. An improved version of the 2SFCA method is the kernel density 2SFCA (KD2SFCA) method. However, this method was not developed to analyze access to health care and it computes scores that express only the spatial access dimensions of proximity and availability. In this paper we present a new method, based on the KD2SFCA method, which improves health care access analysis and better identifies populations that are less empowered to use health care. We adapt the KD2SFCA method for the context of health care access analysis and extend it to capture additional access dimensions. We applied the extended method to the Portuguese hospital health care sector in a case study, and compared its results with those obtained with the KD2SFCA method. Our method was able to improve the identification of the less empowered populations and discovered that they represent 8.1% of the total population, instead of 4.6%, and reside in sixteen of the eighteen Portuguese districts, instead of in thirteen, as identified by the original KD2SFCA method. By improving the KD2SFCA method for the identification of the less empowered populations, our method can be a first step in an endeavor to identify opportunities to increase the health care supply or to redistribute supply resources, with the objective of increasing the access of those deprived populations.

Health-related quality of life and preferred health-seeking institutions among rural elderly individuals with and without chronic conditions: a population-based study in Guangdong Province, China

The aim of this study was to examine health-related quality of life (HRQL) as measured by SF-36 and to identify these factors and the preferred health-seeking institutions of 12,800 persons aged 60 and older with and without chronic conditions in rural areas of Guangdong Province by multistage stratified cluster sampling method. HRQL among rural elderly subjects with chronic conditions was lower than that of elderly subjects with no chronic conditions. Multiple linear regression showed that marital status, living with children, cardiovascular disease, osteoporosis, cataract disease, and mental disease were the main affecting factors of HRQL. The main preferred health-seeking institutions selected by the rural elderly were community/town health service institutions, district hospitals, or secondary hospitals. Our findings indicate that the elderly in rural areas of Guangdong Province have a poor HRQL and incorrect health-seeking pathway. The healthcare policymakers should emphasize the need of developing effective and targeted community services strategies to improve the elderly individuals' HRQL in rural areas of China.

Patient satisfaction with community pharmacy: comparing urban and suburban chain-pharmacy populations

BACKGROUND

Patient satisfaction with pharmaceutical care can be a strong predictor of medication and other health-related outcomes. Less understood is the role that location of pharmacies in urban or suburban environments plays in patient satisfaction with pharmacy and pharmacist services.

OBJECTIVES

The purpose of this study was to serve as a pilot examining urban and suburban community pharmacy populations for similarities and differences in patient satisfaction.

METHODS

Community pharmacy patients were asked to self-administer a 30-question patient satisfaction survey. Fifteen questions addressed their relationship with the pharmacist, 10 questions addressed satisfaction and accessibility of the pharmacy, and five questions addressed financial concerns. Five urban and five suburban pharmacies agreed to participate. Data analysis included descriptive statistics and chi-square analysis.

RESULTS

Most patients reported high levels of satisfaction. Satisfaction with pharmacist relationship and service was 70% or higher with no significant differences between locations. There were significant differences between the urban and suburban patients regarding accessibility of pharmacy services, customer service and some patient/pharmacist trust issues.

CONCLUSIONS

The significant differences between patient satisfaction in the suburban and urban populations warrant a larger study with more community pharmacies in other urban, suburban and rural locations to better understand and validate study findings.

Do more hospital beds lead to higher hospitalization rates? a spatial examination of Roemer's Law

BACKGROUND

Roemer's Law, a widely cited principle in health care policy, states that hospital beds that are built tend to be used. This simple but powerful expression has been invoked to justify Certificate of Need regulation of hospital beds in an effort to contain health care costs. Despite its influence, a surprisingly small body of empirical evidence supports its content. Furthermore, known geographic factors influencing health services use and the spatial structure of the relationship between hospital bed availability and hospitalization rates have not been sufficiently explored in past examinations of Roemer's Law. We pose the question, "Accounting for space in health care access and use, is there an observable association between the availability of hospital beds and hospital utilization?"

METHODS

We employ an ecological research design based upon the Anderson behavioral model of health care utilization. This conceptual model is implemented in an explicitly spatial context. The effect of hospital bed availability on the utilization of hospital services is evaluated, accounting for spatial structure and controlling for other known determinants of hospital utilization. The stability of this relationship is explored by testing across numerous geographic scales of analysis. The case study comprises an entire state system of hospitals and population, evaluating over one million inpatient admissions.

RESULTS

We find compelling evidence that a positive, statistically significant relationship exists between hospital bed availability and inpatient hospitalization rates. Additionally, the observed relationship is invariant with changes in the geographic scale of analysis.

CONCLUSIONS

This study provides evidence for the effects of Roemer's Law, thus suggesting that variations in hospitalization rates have origins in the availability of hospital beds. This relationship is found to be robust across geographic scales of analysis. These findings suggest continued regulation of hospital bed supply to assist in controlling hospital utilization is justified.